Refusal on possible SI patient?

chickj0434

Forum Lieutenant
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So we were dispatched for an evaluation at home. Patient is 48 year old female. Has a hx of psych issues. Pd is on scene as well. Pts father states he believes pt took a bunch of her medication which were sleeping pills and said she wanted to kill herself. Pd stated they checked her medication and no extra pills were missing. Pd states they are familiar with patient as well. Pt is alert and oriented and making sense and having clear rational thoughts. Pt denies taking any meds and denies SI. Pt states she went for drive to cool off after an argument. Pt states she does not want to kill herself. Pd states they feel comfortable and are not going to section here. Ambulance crew obtains refusal from patient.

Any wrong here obtaining a refusal. What do you guys do regarding third party information when family members say pt states something when they are possibly just in the heat of the moment.
 

DrParasite

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So if the cops aren't going to force them to go against their will, what are you going to do? you can't take them kicking and screaming, at least not without getting charged with kidnapping. Not that I think doing so would be in the best interest of the patient.

if you have any concerns, I would contact a supervisor, but at the end of the day, if they don't want to go, PD isn't going to force them to go, then patients have the right to make stupid decisions about their own medical care.
 

Jim37F

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So you have an alert and orientated patient with no medical complaints, and no evidence of anything wrong, just a third party making claims that available evidence doesn't support (claimed the patient took pills, but no missing pills).

I fail to see any reason to kidnap this patient against their will.
 

EpiEMS

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Refusal, witnessed by the ranking PD officer on scene.

Document everything.

If you are ever really uncomfortable, call for a supervisor and/or have medical direction involved. That is good medicolegal practice as far as I know.
 

johnrsemt

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What EpiEMS and Jim37F said: but document the crap out of everything, including what the patient said, and the caller (RP) said. including name of the caller.
2 or 3 sets of VS.
These are the runs that can come back to bite us in the butt. If you don't transport them and they did OD on something, then everyone blames it on you. If you do force them to go to the hospital and there is nothing wrong with them, then everyone questions why did you make them go? and they never get the help they need
 

Tigger

Dodges Pucks
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What EpiEMS and Jim37F said: but document the crap out of everything, including what the patient said, and the caller (RP) said. including name of the caller.
2 or 3 sets of VS.
These are the runs that can come back to bite us in the butt. If you don't transport them and they did OD on something, then everyone blames it on you. If you do force them to go to the hospital and there is nothing wrong with them, then everyone questions why did you make them go? and they never get the help they need
Two or three sets of vital signs? To prove what?

Third party caller with the party in question able to make their own decisions and no obvious attempts at self harm or any statements in support of that. The first thing I'm going to ask is if the party even wants to be evaluated, they can freely tell us to leave before we even have a discussion and that would be entirely their right.
 

dutemplar

Forum Captain
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If the caller wants to file a petition to have law enforcement assist with an involuntary mental health evaluation (Pennsylvania 302), we’ll wait.
I can not lawfully state “in the name of the department of health, I hereby medically detain and kidnap you.”
 

DrParasite

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Is this still a thing?
is what still a thing? the cops mandating an involuntary mental health evaluation, or taking someone into "protective custody" and making the decisions for them? that's a law enforcement thing, not EMS. there are some mental health people (crisis works, trained professionals) who can do it too, but the enforcement of the involuntary hold falls to PD.
 

Tigger

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I would say half the time I take someone to the hospital on involuntary terms there is no mental health hold written by law enforcement. We take people that are imminent threats to themselves or others on standing orders, medical direction no longer wants us to bother calling in to “get em on a hold” as they can’t actually place a mental health hold over the phone.

I imagine other states/regions work differently.
 

DrParasite

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I would say half the time I take someone to the hospital on involuntary terms there is no mental health hold written by law enforcement. We take people that are imminent threats to themselves or others on standing orders, medical direction no longer wants us to bother calling in to “get em on a hold” as they can’t actually place a mental health hold over the phone.
So let's be real for a minute... when that patient file kidnapping charges against you, because you had no legal right to take them somewhere against their will, and no written mental health hold from law enforcement, and your medical directory can't place a mental health hold over the phone, what will your defense be?

I am not saying I haven't stretched the abilities of what I can do in my career, and the only reason I didn't get in trouble because no one complained or looked too hard at what was done, but just because you got away with it, doesn't mean it was legal
 

Tigger

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So let's be real for a minute... when that patient file kidnapping charges against you, because you had no legal right to take them somewhere against their will, and no written mental health hold from law enforcement, and your medical directory can't place a mental health hold over the phone, what will your defense be?

I am not saying I haven't stretched the abilities of what I can do in my career, and the only reason I didn't get in trouble because no one complained or looked too hard at what was done, but just because you got away with it, doesn't mean it was legal
It is in my guidelines which are based on the Acts Allowed as codified in state statute. Do you really think our physician advisor group (which is the largest system in the Colorado with combined medical direction), would put forth such that guidance if that was illegal?

I noticed that you left out the last part of my comment, the part where it might be different where you work or live. Anywho, here is our guideline. I am not suggesting this applies to everyone, just that it is how our system works.
FEA386FD-650B-42A6-93EB-B98AC54CE94B.jpeg
 

DrParasite

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It is in my guidelines which are based on the Acts Allowed as codified in state statute. Do you really think our physician advisor group (which is the largest system in the Colorado with combined medical direction), would put forth such that guidance if that was illegal?
That's a great question... I would counter with the question of do you think the "Sedgwick County Medical Society," who cleared EMS Medical Director Dr. John Gallagher of any wrongdoing following a review of the incident in Wichita Kansas, would ever give such guidance if the actions provided were illegal? And I'm not saying they were intentionally putting forth illegal guidance, but has a court of law ever stated that it was legal? or has no one ever challenged it in court?

I'm sure your physician advisor group is awesome and never wrong, but I did look at the Colorado EMS regulations (6 CCR 1015-3 in case anyone was interested), and I didn't see where it said that EMS providers had the authority to force a person to go to the hospital against their will. I did see that all providers can use restraints but did not see where the law clearly stated that EMS providers could restrain someone against their will, and force them to receive treatment, without an MD or LEO enacting a mental health hold. Can you point out the section?
 

FiremanMike

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A lot of times, it’s like porn - you may not be able to define it, but you know it when you see it.

I’d have to pull the stats, but ketamine for sedation of combative patients is one of our more frequently given medications. It doesn’t take a rocket engineer to identify patients who require chemical restraint, and it’s pretty rare that those folks are on law enforcement medical holds.

I am perfectly comfortable articulating why I restrained a patient who was a danger to themselves.
TL:DR - our rules of engagement (and in this entire area) are pretty much the same as @Tigger
 

DrParasite

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A lot of times, it’s like porn - you may not be able to define it, but you know it when you see it.
while true, there are legal definitions, described in case law:
I am perfectly comfortable articulating why I restrained a patient who was a danger to themselves.
I completely understand, and I (and likely @Tigger) can do the same. To my supervisor, to my medical director, and maybe even to a jury (haven't ever had to do that though). And your reasoning might be sound; the question becomes, does the law give you the legal authority to restrain someone, and force them to accept treatment against their will, or does that responsibility/authority lie with law enforcement or another party? Because the jury might agree with you (assuming the attorney's expert witnesses don't tear you to shreds on the witness stand), but if the law doesn't say you can do it, you might still end up in a world of hurt when the judge rules on the law as it is written.
 

EpiEMS

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I did see that all providers can use restraints but did not see where the law clearly stated that EMS providers could restrain someone against their will, and force them to receive treatment, without an MD or LEO enacting a mental health hold.
Does it necessarily need to state this? Is it not a common medicolegal practice for a patient without capacity to be restrained & transported if indicated?
 

DrParasite

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Does it necessarily need to state this? Is it not a common medicolegal practice for a patient without capacity to be restrained & transported if indicated?
Great question, one I don't know the answer to, however since there are some mediolegal practice that states who can take someone against their will (if i remember correctly that was restricted to, law enforcement, a judge/magistrate, and a doctor, as well as some other behavioral specialists, were allowed to file the proper paperwork, and use force to enforce their order), I would imagine there is some historical reason.

Now, if we accept the assumption that it isn't needed, why do we have a 5150 paperwork or PA 302 (or your local jurisdiction's code to apply an involuntary hold) at all? After all, if it isn't needed, just call the ambulance and if they feel the person lacks capacity, just have them drag the person kicking and screaming.

After all:
I can not lawfully state “in the name of the department of health, I hereby medically detain and kidnap you.”
 

EpiEMS

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Great question, one I don't know the answer to, however since there are some mediolegal practice that states who can take someone against their will (if i remember correctly that was restricted to, law enforcement, a judge/magistrate, and a doctor, as well as some other behavioral specialists, were allowed to file the proper paperwork, and use force to enforce their order), I would imagine there is some historical reason.

Now, if we accept the assumption that it isn't needed, why do we have a 5150 paperwork or PA 302 (or your local jurisdiction's code to apply an involuntary hold) at all? After all, if it isn't needed, just call the ambulance and if they feel the person lacks capacity, just have them drag the person kicking and screaming.

After all:

All fair points, [mention]DrParasite [/mention] , I think it’s going to involve some research on my part! I did see a https://nasemso.org/wp-content/uplo...-Emergency-Medical-Services-Practitioners.pdf guidance from NAEMSP in consensus with a few other practitioner orgs that may be of interest. In general, I think the principle of implied consent is the main driver here - they cannot consent affirmatively due to AMS.
 

GMCmedic

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That's a great question... I would counter with the question of do you think the "Sedgwick County Medical Society," who cleared EMS Medical Director Dr. John Gallagher of any wrongdoing following a review of the incident in Wichita Kansas, would ever give such guidance if the actions provided were illegal? And I'm not saying they were intentionally putting forth illegal guidance, but has a court of law ever stated that it was legal? or has no one ever challenged it in court?

I'm sure your physician advisor group is awesome and never wrong, but I did look at the Colorado EMS regulations (6 CCR 1015-3 in case anyone was interested), and I didn't see where it said that EMS providers had the authority to force a person to go to the hospital against their will. I did see that all providers can use restraints but did not see where the law clearly stated that EMS providers could restrain someone against their will, and force them to receive treatment, without an MD or LEO enacting a mental health hold. Can you point out the section?
 

DrParasite

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Thanks @GMCmedic, I didn't think to look in the legal briefs related to Emergency Mental Health hold... good catch!

I looked at the actual brief, which says this statement:
A 72-hour mental health hold can be initiated by an intervening professional, including a certified peace officer, medical professional, registered professional nurse with training in psychiatric or mental health nursing, licensed marriage and family therapist or counselor with training in mental health, or licensed clinical social worker. Additionally, a hold can be initiated upon an affidavit sworn to or affirmed before a judge that establish that a person appears to have a mental illness and, as a result of such illness, appears to be an imminent danger to himself or herself or others, or gravely disabled.
If Colorado's state statutes consider paramedics medical professionals (in the legal sense because the brief explicitly required RNs to have training in psychiatric or mental health nursing & family therapist or a counselor with training in mental health, and doesn't group them under the title of "medical professionals") then awesome. I am curious if other states do as well, or if this is limited to Colorado.
 
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