Refusals

[firefighter85]

I recently ran a call for a psychiatric Pt. Upon arrival at the Pt. residence I was met by PD, where they stated the Pt was intoxicated and crying. As I made my way into the residence I noticed 2 family members upset, and not evidence of any alcohol. The Pt was A/O x3, alert to date, time, place, and knew what was going on. She was very uspet, and there was no smell of sign of ETOH. Attempts to calm the Pt down were unsucessful, and pt actually pushed me away. The family members stated she needed to go to the hospital, but she refused. Med Control advised us that we could get a refusal due to Pt being A/O. As we attempted to obtain a refusal signature the Pt stated she would not sign the refusal, nor would the family members. The Pt told us to leave, and the family said the same. I obtained a signature from PD as a witness to what happened. There were numerous witnesses that saw the Pt, and the family. Is there anything that could have been done different or handled differently, and has anyone had this happen before?

 

[VentMedic]

If you are in the state of Florida, yes, there is more that could be done especially with PD present.

If there was any suspicion of the patient being intoxicated, how well do you think the patient's signature would have held up in court if they had actually signed the refusal?

Appearances can be deceiving. I've seen EMTs, Paramedics, RNs and MDs with alcohol levels well over the legal amount still functioning well enough to be A/O x 3 as well as doing patient care. That is, until they were cornered for an intervention willingly or not.

 

[fma08]

Why did PD think that there was ETOH involved?

 

[KEVD18]

in ma, if the patient appropriatley answered the assesment questions and is of the age of majority, they can refuse. i wouldnt have called olmc, but if i had i would have gotten slapped for it.

my olmc or one of the canarys present could have issued a pink slip for the pt, but if they arent a significant risk to themselves/others thats not going to happen.

i would have doc'd it as "ems activated by pd/third party. pt neither requested nor allowed medical assesment or tranportation. pt refused to sign refusal. witnessed by xxxx. clear and in service."

 

[Outbac1]

We run accross that all the time. Unless there is evidence that the pt has or will attempt to harm themselves police won't arrest them under the mental health act. That's not to say they don't need to go to the hosp., we're just not taking them. The family can take them if they feel that strongly about it but we are not going to kidnap them. Here it dosn't really matter if they are drunk or sober. If we can't convince them to go they stay whether they sign a refusal or not. If they have or may attempt to harm themselves it becomes a police matter.

Sometimes you can convince them to go, sometimes you can't.

 

[mikeylikesit]

nothing more that you could have done. you made all of your attempts and exhausted all of your options. just get the witness statement from a sworn officer and off you go. i couldn't tell you what you could have done had PD not been present though.

 

[skyemt]

things are just not so simple...

just because someone is A&O x 3, does not mean they are not altered mental...

what if someone answers the questions correctly (A/O x3), but the family says they are not acting themselves?

would you let them sign a refusal form?

what if someone was having TIA's, but you caught them when they were alert and oriented?

don't you think there is more to it than three questions?

 

[KEVD18]

its not three questions, its as many questions as it takes to satisfy me that they are alert and oriented.

i cant take someone to the H against their will just because they "arent acting themselves". you havent had a bad day where you were medically fine but for whatever reason you acted differently? i can think of several such examples: breakup, death of a friend, personal trouble. any of those will make me agitated, aggressive, irritable etc but i dont need to go be evaluated for them. all of the above and more would certainly cause my friends and family to say "he isnt acting himself".

after determining that they are in my professional opinion able to decide to refuse treatment, every refusal gets the speech, which goes something like this:

sir/ma'am: im required to inform you of the following. at this time, i am unable to completely establish whether or not you are suffering from a potentially life threatening illness/injury. the only person able to make that determination is a physician at the hospital. while i can not force you to go or take you against your will, i can strongly recommend that you allow me to transport you their for further evaluation. should you choose to refuse treatment or transportation, you accept full responsibility for any further progression of your injury or illness. you understand that this could include permanent disability or death. do you wish to be treated and transported and do you wish to refuse the services offered?"

if they say no, "press hard, your making three copies. please dont hesitate to call us back if you change your mind."

end of story. i have not, nor will i ever, take a patient against their will unless i have either a valid involuntary commitment order or a patient that is unqualified to refuse treatment.

 

[BEorP]

things are just not so simple...

just because someone is A&O x 3, does not mean they are not altered mental...

what if someone answers the questions correctly (A/O x3), but the family says they are not acting themselves?

would you let them sign a refusal form?

what if someone was having TIA's, but you caught them when they were alert and oriented?

don't you think there is more to it than three questions?

Exactly... a capacity assessment involves a lot more than just this "A&O x3" stuff.

 

[BossyCow]

So, besides being intoxicated, why did the police think the pt needed EMS. Unless they are approaching alcohol poisoning, drunk isn't really an EMS issue.

We had a frequent flier like this. The issues were psych but not life threatening. She'd just get drunk and fall down. We did take her in a few times, but on those occasions, she had medical issues related to or that caused the fall. Once for a cerebral bleed, which was tricky because the symptoms weren't that much different from her usual drunken state.

We eventually had to call in adult protective services. But in this case it was pretty obvious that the pt was unable to care for herself and in a deteriorating state of mental and physical health. One month we had almost 20 calls to her residence, with 4 in one day.

I would document everything, do a full on physical exam, if the pt would allow it. It said you were called to a psych call, did the pt have a psych history or was this the police's assessment? Also, if the cops said Alcohol, what did they base that on? Reports of the family? Our LEOs carry breathalyzers so if they say ETOH, they generally can produce the proof for us.

 

[K9kazoo]

Armchair quarterbacking....

Did the local PD call EMS just for an assessment or did family call?

What was the original dispatch info?

Was this pt hemodynamically stable? v/s taken? Normal range? A/0x4... person, place, time, events?

No evidence of drugs/ETOH?

Pt a risk to self or others?

If you felt strongly about her attending to a local ER... is your PD allowed to "assist" the pt based on your concerns?

I've attempted to attached a pdf file of our cancellation policy which was a direct result of several calls that were canceled and went bad... however the attachment size is too small... Mods???

B.

 

[firefighter85]

K9Kazoo... I appreciate your reply. Dispatch info consisted of a psyhch pt. No other info was given. I believe the family called, and PD was on-scene prior to our arrival. Pt was A/O x4, knew exactly what was going on, and was just crying. Pt was at her residence in her bed room, and family members stated that she may have been drinking, but they didn't know how much or even if she had. They just thought she may have been. No evidence of drugs, nor ETOH. Pt has a Hx of alcohol abuse. Pt would not let myself nor my partner touch her, nor was she willing to let us assess her. She was not a threat to herself and others, and was just upset. Family members stated that she has moments like that very often, and essentially wanted us to get her off their hands. By Tx the pt, PD stated it would have been kidnapping. The Pt nor would the family sign a refusal form, but signatures were obtained from PD as a third party witness to what had occured. Extensive documentation was also preformed. This type of call was definintly a first for myself.

 

[K9kazoo]

K9Kazoo... I appreciate your reply. Dispatch info consisted of a psyhch pt. No other info was given. I believe the family called, and PD was on-scene prior to our arrival. Pt was A/O x4, knew exactly what was going on, and was just crying. Pt was at her residence in her bed room, and family members stated that she may have been drinking, but they didn't know how much or even if she had. They just thought she may have been. No evidence of drugs, nor ETOH. Pt has a Hx of alcohol abuse. Pt would not let myself nor my partner touch her, nor was she willing to let us assess her. She was not a threat to herself and others, and was just upset. Family members stated that she has moments like that very often, and essentially wanted us to get her off their hands. By Tx the pt, PD stated it would have been kidnapping. The Pt nor would the family sign a refusal form, but signatures were obtained from PD as a third party witness to what had occured. Extensive documentation was also preformed. This type of call was definintly a first for myself.

Just crying... refusing assessment... non-compliant... may have been drinking??? ='s a trip to the ER in my mind... better safe than sorry and alway CYA (cover your 6)...

or

close your eyes and think of the next answer at the inquest :sad:

firefighter85... where ya from... what local... Canada, USA, abroad???

B.

 

[ffemt8978]

Just crying... refusing assessment... non-compliant... may have been drinking??? ='s a trip to the ER in my mind... better safe than sorry and alway CYA (cover your 6)...

B.

You would take somebody to the hospital against their will just because they don't want you to touch them, are crying, and may have been drinking??? :sad:

Around here, you sure would need to cover your 6...although it would be from your new cell mate named "Ben Dover".

I'm curious as to what your justification for kidnapping your patient would be?

 

[K9kazoo]

I'm curious as to what your justification for kidnapping your patient would be?

I think you'd agree our two countries/departments have different laws/policies in the way we'd handle things...

B.

 

[Jon]

I think you'd agree our two countries/departments have different laws/policies in the way we'd handle things...

B.

The question falls to mental competence. If the patient isn't willing to allow an exam, and there is any question of the patient's mental status being less than totally normal... then at the least, you should contact command and punt the ball to someone at a higher pay grade.

If you can justify that the patient isn't mentally competent to refuse and/or is a threat to themselves or others, you, and/or PD might have the ability to transport them against their will.

If you can't justify what amounts to kidnapping (taking someone against their will)... then there isn't much choice except to get some form of refusal. If the patient refuses to sign... your only option is to get witness signatures and document, document, document.

 

[firefighter85]

The Pt was extreamly non-compliant, and knew exactly what was going on. Med-Control was contacted and notified of the situation, and stated that if she was mentally competent, A/O x4, and all she was doing was crying then we could obtain a refusal. There was no way she was getting on our strecher on her own will, and she stated that. I guess you just had to be there to see it.

 

[KEVD18]

i wonder if her non compliance was due to the 3+ uninvited guests in her house asking her all sorts of questions, trying to get het to succumb to a physical exam. people that she didnt call, doesnt need and damn sure doesnt want?

anybody who says they would take that patient against their will; i hope you will enjoy the court proceedings related to your kidnapping, losing your license, and the working at home depot.

 

[jazminestar]

i would have called base hospital and see what they had to say, if this person is this upset and it's not normal for them (even if it has happened a few times before, if it's not a <i>regular</i> thing, then it's not normal) something really could be wrong that no one wants to talk about......if it was here in san diego, and it was clear with base hospital, i would have asked pd to place a 5150 hold on her and took her to the er......we can't always assume just because a pt is a&o x3 or x4 that they are okay.........regardless, you were called in for a reason right? maybe if you were able to talk to the pt without all the family and pd around, the pt might have been more open to tell you what was going on......

 

[KEVD18]

the point here is blowing right by you. yes, there is obviously something wrong. that is not synonymous with something is medically wrong. she's crying with no immediatley apparent physical injury. that leads me to believe its an emotional problem. heres a possible scenario:

the pt in question is a 33y/o female. she has been dating a guy she really likes for oh say three years now. her menstrual period this month was two weeks late, so she though she was pregnant, which whe was thrilled about. she thought finally, i love this guy, and now were going to have a baby. things are finally going right for me. then, on the morning in question, she gets her period. she had gotten so excited about the though of having a baby with fred and now her dream was shattered. so she cries. she doesnt tell anybody whats wrong because she never told them her suspicions and she wants to keep her undying love for fred private.

now, for all you future kidnappers out there, where is the benefit of taking this girl against her will? first, youd have to physically abuse her to get her in the bus. handcuffs if you have cops handy, 4 pt leathers when you get to the bus, same when you get to the ed. all sorts of people coming in and asking very personal question to a person that just wants to draw a hot bath, inhale a bottle of merlot and cry it out. she doent want to talk to fred, her sister, mother, you, the cops, the docs. nobody. she just want to be alone and cry. and some of you guys want to involuntarily commit her. bravo folks, bravo.

appropriate answers to assesment questions(not limited to three), appropriate mental competence, age of majority and no contivening involutary commitment order = "press hard, three copies. have a nice day".

or you could abuse and kidnap somebody. your call really.