Suicidal patient refusal?

Jim37F

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So you were dispatched 911 for a suicidal patient. They're A&O x4, GCS 15, they asked someone at the board and care place they live at to call because they're suicidal with a plan to run into traffic.

Pt has a history of bipolar, schizophrenia, and high cholesterol, no known allergies, and is non compliant with meds, doesn't take any, can't even remember their names.

Pt is otherwise calm, cooperative and is requesting to go to the local hospital that has a Psychiatric Emergency Dept to see someone for the suicidal thoughts.


Cut to 3 hours later, you're registered and triaged and sent to the Psych ward. It's the kind of place with the big locked door and you're expected to wait out in their waiting area until they call you in. It's been 3 or so hours, just waiting (which is known to be.....not unusual for this place by other crews).

However, after waiting on the gurney for hours, your patient is starting to get more and more agitated, telling you she wants to walk out and leave stating she's "feeling fine and all better". The main ERs attitude for patient AMAs off EMS gurneys for BLS patients is pretty much "if they're A&O and can stand and walk on their own power without assistance, the exit is down this hall....you need a nurse signature saying you actually brought them in? Here ya go, k thx bye"

So since our SI patient isn't on a legal hold of any kind, isn't being restrained, or anything else....are they free to walk out AMA same as above? Does the fact that they're SI mean we have to keep them from leaving? Is it provider discretion?

(Note, I'm not actually asking for legal advice for a specific situation, the actual patient this scenario is based on who got me curious was actually transferred to the M.D. in the Psych ward.....im curious as to how you would handle the situation in your area in your system under your laws/policies/SOPs/etc)
 

DesertMedic66

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Any suicidal patient is placed on a psych hold prior to me transporting to avoid this issue. I have almost been burned before. I also don’t trust PD when they say “oh, we will meet you at the ED and finish the paperwork there” as I have almost been burned with that also (ended up getting our supervisors, PD Lieutenant, and hospital medical director involved).

Since you are in the hospital it is their patient now. I would have walked up to the charge nurse and simply stated what was going on and that it is their patient. If they wish to let the patient sign AMA that is on them. I have my signature stating I handed over all patient care to RN Jane.
 

captaindepth

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Does this patient pose a danger to themselves or others? They stated their plan was to walk into a traffic in an attempt at self harm and now, hours later, they want to walk out of the hospital and out of YOUR care. I believe they have demonstrated themselves to be a risk to themselves due to their statements (made while sober, alert, and orientated) but also to the public due to wanting to run into traffic. Also the patients diagnosed medical hx is concerning for rapid changes in presentation/combativeness. I think there is enough there to hold the pt against their will under implied consent and I would not let them leave. We have arm restraints permanently affixed to our stretchers, arms go in the restraints, leg and chest belts tightened and they aren't leaving.

The fact that a patient on an ambulance stretcher, in the care of EMS, would have to wait in a hall for 3 hours is OUTRAGEOUS!!!!! I'd be livid with the ED and I'd let them know it. If the pt continued to escalate in the ED I wouldn't take any immediate action and continue to insist the ED does their job, if they refuse I'd treat the patient right there in front of them. Then I'd start making some phone calls.

It's a tough situation for sure and easy to arm chair quarterback the call. In reality there are is a lot of situational factors that come into play but I try to remember to do what's best for the patient, and if the patient walks out of that hospital and jumps in front of a bus then I would be destroyed for a multitude of reasons.
 

aquabear

World's Okayest Paramedic
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This smells like some bush league Harbor General s**t.

Anyways... here in Texas, if they have decisional capacity, aren't on a legal hold or in protective custody, they can sign my refusal form and peace out. Now my partner will be calling for PD/CIT at the same time this is all going down, and they can sort it out.

In your case, I would have just rang the door bell to the Psych ER and tell them what's about to happen with your/their Pt.
 

Tigger

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We don't really do holds here anymore for scene calls. If you think the patient is suicidal and you want to use some physical/chemical restraint, do so. If the patient puts you in danger, you leave and it becomes an LE issue, not because of SI but because they attempted to harm others. When we transport by ambulance (which at my FT job is rare, but I'll spare everyone my spiel on our community paramedic mental health program), you go right to a bed. We don't hold the wall here anyway. Usually it's in the psych hall, and if it isn't, security will watch them. The attending can then choose to place a hold or not.
 

SpecialK

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It is being strongly reinforced that this is a medical / ambulance / health issue. Not a police issue. Apparently, staff were calling the police a bit too frequently for "help" when it wasn't necessary and the police have been successfully prosecuted for "helping" ambulance personnel (which means restraining people) when they were not legally authorised to do so. To that end, the police are only to be requested if the patient is creating imminent danger.

In this scenario, where the patient was taken to ED but wants to walk out ... well, that's up to the hospital to deal with honestly. I would be happy to get involved assisting them but if they want to do anything then their clinical personnel need to do it.
 

EpiEMS

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All of the suicidal ideation patients I've ever had have been put on a PD hold ("emergency commitment") either while we were on scene or prior to our arrival. PD will ride with us or follow closely behind. Rarely have I had a need for restraints (chemical or otherwise).

Now, given that this particular patient was not on a hold of any kind, and you've transferred care -- this is on the hospital/RN. (I might try and suggest to the patient that they stick around for the psych ED, though. Not sure if that would backfire?)
 

Akulahawk

EMT-P/ED RN
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For the suicidal patient that's not on a hold, that's alert and oriented, that's not combative, if the patient wants to leave, so be it. You have very little (if anything) usually available to legally prevent them from leaving. Simply because they say they're suicidal and have a plan, if they're not on a hold and they're not under arrest, they have the same rights as anyone else does to just up and leave. If the patient becomes combative, that's a different issue. I'll put those people in restraints to prevent injury to myself and to the patient.

However, in the particular situation in this thread, the patient has been registered, triaged, probably has been seen by a provider to be determined medially clear to go to a mental health unit... if the patient that's not on a hold wants to leave, notify the staff and document who you notified. The patient is now really the hospital's problem and they should have taken the patient off your hands as soon as the patient was deemed OK to go to the mental health unit. Transport within the facility isn't usually an EMS responsibility.
 

hometownmedic5

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Wait a minute. You're routinely committed to calls for hours after you get to the hospital? And your employer is ok with that? How in the world are you able to stay in business with UHUs that low?
 

EpiEMS

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You're routinely committed to calls for hours after you get to the hospital?
I believe @Jim37F has indicated in the past that this is common practice (inexplicably, I know) in LA for BLS services
 

Carlos Danger

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The fact that a patient on an ambulance stretcher, in the care of EMS, would have to wait in a hall for 3 hours is OUTRAGEOUS!!!!! I'd be livid with the ED and I'd let them know it. If the pt continued to escalate in the ED I wouldn't take any immediate action and continue to insist the ED does their job, if they refuse I'd treat the patient right there in front of them. Then I'd start making some phone calls.
This. The ED keeping a patient waiting and an EMS unit tied up for that long is absolutely unacceptable.
 

hometownmedic5

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I'm not even thinking about the patient yet. Yeah, I know I probably should start there, but I can't get past the money part.

I truly don't get how a company can stay in business racking up a hot two calls per truck per shift.

Well done Californian EMS, You've done it again...
 

DrParasite

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In California, the ambulance companies willingly provide free staffing to the hospitals who refuse to staff appropriately, because their EMS crews will monitor the patients until the hospital decides to find them a bed. This is a common practice (and one that blows my mind too).

Apparently EMTALA doesn't apply to them (the whole once you are on the hospital property, and cross the ER doors, the hospital becomes the responsible party for the patient (http://www.medlaw.com/do-ambulance-jam-ups-at-hospitals-violate-emtala/)

However, after waiting on the gurney for hours, your patient is starting to get more and more agitated, telling you she wants to walk out and leave stating she's "feeling fine and all better". The main ERs attitude for patient AMAs off EMS gurneys for BLS patients is pretty much "if they're A&O and can stand and walk on their own power without assistance, the exit is down this hall....you need a nurse signature saying you actually brought them in? Here ya go, k thx bye"
It's a hospital issue. if the patient wants to go, the ER won't stop them, and will sign your paperwork accepting that you brought them there, let them go. It's an EMTALA issue, and I'm sure they could get jammed up for it (but again, california does some..... special things that wouldn't fly elsewhere), but it's not your issue.

You did your job taking them to the hospital. What the hospital does with your patient isn't your responsibility.
 
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DrParasite

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hometownmedic5

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A routine delay of greater than 30min or a special circumstances delay of greater than an hour would turn my dispatchers and supervisors into an apoplectic nightmare.

We'll just add this to the seemingly never ending list of things regarding California that make me shake my head...
 

captaindepth

Forum Lieutenant
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Just curious, for you guys out there who have to "hold the wall" with patients on your stretcher do the hospitals give preference to certain agencies? So if numerous agencies are all waiting for a room with the same BLS patient will the ED play favorites with who gets a room first?
 

VentMonkey

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Just curious, for you guys out there who have to "hold the wall" with patients on your stretcher do the hospitals give preference to certain agencies? So if numerous agencies are all waiting for a room with the same BLS patient will the ED play favorites with who gets a room first?
Nope, patient acuity. Any, and all patients that meet criteria for higher acuity will continuously push the unit back in terms of offloading.

After the higher acuity patients are sorted, they'll typically figure out which low-level patient requires a bed over triage according to the "first come, first serve" motto. Most of us in my area who've been doing it a while know which hospitals want what offloaded into their lobby. You also get to know your MICN's as well as their personalities, and preferences.
 

captaindepth

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I assumed patient acuity took priority, which is why I was wondering if all patients were the same BLS patient would there be any agency preference.

The idea of having to wait that long for the hospital assume care of a patient is mind boggling to me. We transport to 12 different hospitals and all of them will have bed assignments (or triage) prior to our arrival. When there is no rooms available they will start filling up hallway beds (report and care are still transferred to a nurse and sometimes a doc upon EMS arrival), once the hallway beds are full they go on ED divert. Its rare we have a patient on our stretcher for more than 5-10 minutes after we arrive in the ED. We are available for the next call as soon as we arrive at the ED with the patient, if we don't get a call we are expected to clear and go back into service in 20 minutes. I think our system would implode if we had hour + wait times in the ED. Crazy.
 

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