Suicidal patient refusal?

bakertaylor28

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Because any patient that needs an ambulance is at a higher risks for cardiac arrest.

See how anecdotal evidence works?

Id argue that in my experience, more patients have spontaneously coded than those that up and decided to be combative.

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I'd agree with that- which is why, personally, I think the policy is poorly written. But I suspect political influence goes into these things.

Wheres the mods? Usually when im battling a troll place is shut down by now?

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I've given my opinion, and I'm sorry you didn't like it. I've said pretty much all I have to say on the subject, and hence that point of conversation has ended as far as I'm concerned, unless someone else has something to add. But last time I checked, having an opinion wasn't trolling.
 

gonefishing

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I'd agree with that- which is why, personally, I think the policy is poorly written. But I suspect political influence goes into these things.



I've given my opinion, and I'm sorry you didn't like it. I've said pretty much all I have to say on the subject, and hence that point of conversation has ended as far as I'm concerned, unless someone else has something to add. But last time I checked, having an opinion wasn't trolling.
No comment. I don't need to go to the penalty box today.

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MonkeyArrow

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@bakertaylor28 but you seemed to ignore my response to your post earlier. Where is your source that holding the wall until a bed becomes available is a violation of federal law that the FBI will investigate?
 

Tigger

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I'm not really sure what the community is looking for here. If you don't agree with some content, say so. Or say nothing. That should end the conversation pretty quick.

Some arguments cannot be won, even if you're right.
 

bakertaylor28

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@bakertaylor28 but you seemed to ignore my response to your post earlier. Where is your source that holding the wall until a bed becomes available is a violation of federal law that the FBI will investigate?
My source would be the appropriate federal statutes. Since most of the facilities that accept incoming adult mental health cases are government run (most usually a county hospital) they become subject to not only the patient dumping statutes, but the statutes under 28 U.S.C. 1983, 18 U.S.C. 241, and 18 U.S.C. 242. The 1983 statute provides a civil cause of action against a government-affiliated employee, and the later statutes involve criminal offenses involving constitutional civil rights which government-run agencies are always subject to. The eighth amendment prohibits any government-run agency, which includes any government-run hospital, from violating the eighth amendment cruel and unusual punishment prohibition, which historically includes refusal to provide adequate medical care within a reasonable time frame. What constitutes "reasonable" is an issue of law that the court must decide on a case-per-case basis, and is something that a federal district judge must ultimately decide. [Law enforcement are not allowed to determine what constitutes "Reasonable" for these purposes because no statute defines the term "reasonable" as used in the criminal statutes under 18 U.S.C. et seq.) ].

Hence, the question becomes whether or not it is "reasonable" for a facility to wait one to two hours to examine a psych patient whom, is by DSM-IV defintion, deemed "unstable". (The DSM-IV is considered the holy grail of mental health practice, and is considered to be an absolute authority in the U.S.) Since EMT-P's don't get any psych training whatsoever beyond "stop-gap" measures such as temporary chemical restraint (which has criminal law considerations of it's own to consider and is considered highly problematic unless one can articulate absolute need at the exact moment of time.), We are largely in over our heads in being able to prevent suicide.

This is because a lot of patients whom need chemical restraint to avoid suicide aren't "combative" in the sense it applies to the EMS world- in that they aren't combative against you, but are rather combative against themselves. Therefore, most patients that actually need chemical restraint don't fall within our classic protocol on the subject. We couple that with the fact that, because we're not trained specifically to articulate mental health state in the language that is inherent to "psych" treatment, MC will be reluctant at best to authorize chemical restraint until things have gotten to the point to where in reality it should have been done way before then. Hence, it becomes that the receiving facility is best equipped to handle the definitive emergency procedure as applies to this type of case, where it is beyond the bare basics, and beyond what the EMT-P is prepared to objectively recognize beyond that of the average citizen. (in that anyone can request a mental health hold for an individual.) This is why psych nurses get training beyond that of an R.N. as applies to the mental health field specifically.

The thing is that "stable" has two totally different definitions depending whether we're talking the physical or mental sense- however, the court will follow the "mental" sense in cases of a suicidal patient, which is beyond our scope of training. Hence it becomes the receiving facility is refusing to deal with a clear emergency in much the same way as if we were to wait 3 minutes before initiating CPR in a cardiac arrest. Regardless of "bed space" they have the duty to stabilize the patient within reasonable capability. Waiting an hour to do something without referring the patient to a facility that is equipped to handle the situation more expediently is medically inappropriate and incurs legal liability under the "Reasonableness" doctrine, because a "Reasonable person" in the eyes of the law is a person without advanced training, but a person whom has "common sense".

The potential net result is that the paramedic incurs liability for acting beyond scope of training in accessing the real potential for harm (since we have no formal mental health training) , and the receiving facility incurs liability because their actions were unreasonable in the eyes of the law.
 

DesertMedic66

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So the psych hold that I have written by PD that states the patient “is a danger to themselves” because they want to hang themselves means this patient is unstable and needs a bed ASAP? I think you and everyone else have different views on what stable vs unstable is...
 

MonkeyArrow

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My source would be the appropriate federal statutes. Since most of the facilities that accept incoming adult mental health cases are government run (most usually a county hospital) they become subject to not only the patient dumping statutes, but the statutes under 28 U.S.C. 1983, 18 U.S.C. 241, and 18 U.S.C. 242. The 1983 statute provides a civil cause of action against a government-affiliated employee, and the later statutes involve criminal offenses involving constitutional civil rights which government-run agencies are always subject to. The eighth amendment prohibits any government-run agency, which includes any government-run hospital, from violating the eighth amendment cruel and unusual punishment prohibition, which historically includes refusal to provide adequate medical care within a reasonable time frame. What constitutes "reasonable" is an issue of law that the court must decide on a case-per-case basis, and is something that a federal district judge must ultimately decide. [Law enforcement are not allowed to determine what constitutes "Reasonable" for these purposes because no statute defines the term "reasonable" as used in the criminal statutes under 18 U.S.C. et seq.) ].

Hence, the question becomes whether or not it is "reasonable" for a facility to wait one to two hours to examine a psych patient whom, is by DSM-IV defintion, deemed "unstable". (The DSM-IV is considered the holy grail of mental health practice, and is considered to be an absolute authority in the U.S.) Since EMT-P's don't get any psych training whatsoever beyond "stop-gap" measures such as temporary chemical restraint (which has criminal law considerations of it's own to consider and is considered highly problematic unless one can articulate absolute need at the exact moment of time.), We are largely in over our heads in being able to prevent suicide.

This is because a lot of patients whom need chemical restraint to avoid suicide aren't "combative" in the sense it applies to the EMS world- in that they aren't combative against you, but are rather combative against themselves. Therefore, most patients that actually need chemical restraint don't fall within our classic protocol on the subject. We couple that with the fact that, because we're not trained specifically to articulate mental health state in the language that is inherent to "psych" treatment, MC will be reluctant at best to authorize chemical restraint until things have gotten to the point to where in reality it should have been done way before then. Hence, it becomes that the receiving facility is best equipped to handle the definitive emergency procedure as applies to this type of case, where it is beyond the bare basics, and beyond what the EMT-P is prepared to objectively recognize beyond that of the average citizen. (in that anyone can request a mental health hold for an individual.) This is why psych nurses get training beyond that of an R.N. as applies to the mental health field specifically.

The thing is that "stable" has two totally different definitions depending whether we're talking the physical or mental sense- however, the court will follow the "mental" sense in cases of a suicidal patient, which is beyond our scope of training. Hence it becomes the receiving facility is refusing to deal with a clear emergency in much the same way as if we were to wait 3 minutes before initiating CPR in a cardiac arrest. Regardless of "bed space" they have the duty to stabilize the patient within reasonable capability. Waiting an hour to do something without referring the patient to a facility that is equipped to handle the situation more expediently is medically inappropriate and incurs legal liability under the "Reasonableness" doctrine, because a "Reasonable person" in the eyes of the law is a person without advanced training, but a person whom has "common sense".

The potential net result is that the paramedic incurs liability for acting beyond scope of training in accessing the real potential for harm (since we have no formal mental health training) , and the receiving facility incurs liability because their actions were unreasonable in the eyes of the law.
Ah, now I remember. This guy is the fake lawyer.

You are conflating government funded with government run, first of all. The eight amendment does not apply because no punishment is being carried out by the government. Seeking treatment for psychiatric care is not a punishment issued through the legal system.

You've seemed to lay out a very long explanation of reasonable, which is what the common person would find. Again, hospitals don't make EMS crews wait for fun. The EMS crew is waiting for a bed to clear. No reasonable person would find that a facility at max capacity can somehow abbreviate the wait time for a bed. By doing what, kicking another patient out to make room for the EMS patient?

A psych patient is nothing like a patient in cardiac arrest. One is in immediate and imminent risk of loss of life, the other is not. You even say "within reasonable capability". This means that if no beds are available, you're going to have to wait if you're stable. A non-combative psych patient is stable. By your definition, every abdominal pain or leg pain, which can have a risk of rupturing AAA or DVT turned into PE causing arrest, need to be treated immediately, making every single hospital in the country in violation of federal law since they have people wait in the waiting room.

I really hope you're better at EMS than you are at law.
 

DrParasite

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You know, @bakertaylor28 actually provided a very well written and properly thought out response... He even cited the appropriate legal statutes... I would have added that once you arrive in the ER, your patient becomes the hospitals responsibility (per EMTALA), and by holding the wall for an extended period of time, you are providing free labor to the hospital.

He's still acting like a jackass to the hospital staff, and I wouldn't want to work in the same system as him, but he cited case law and everything. I'm still waiting for him to call the FBI on the hospitals......

BTW, this is a hospital staffing and bed management issue. EMS cannot fix the issue, and should not be used as free labor. EMS should be in the field answering calls, not holding the wall because the hospital doesn't have enough staff or beds to handle the routine influx. In many other states, if you have a 30 minute wait time, than the hospital needs to go on divert, and all patients should be redirected elsewhere, because the hospital obviously can't handle the workload they currently have.

Why this type of madness is permitted to occur in California is beyond me.
 

gonefishing

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You know, @bakertaylor28 actually provided a very well written and properly thought out response... He even cited the appropriate legal statutes... I would have added that once you arrive in the ER, your patient becomes the hospitals responsibility (per EMTALA), and by holding the wall for an extended period of time, you are providing free labor to the hospital.

He's still acting like a jackass to the hospital staff, and I wouldn't want to work in the same system as him, but he cited case law and everything. I'm still waiting for him to call the FBI on the hospitals......

BTW, this is a hospital staffing and bed management issue. EMS cannot fix the issue, and should not be used as free labor. EMS should be in the field answering calls, not holding the wall because the hospital doesn't have enough staff or beds to handle the routine influx. In many other states, if you have a 30 minute wait time, than the hospital needs to go on divert, and all patients should be redirected elsewhere, because the hospital obviously can't handle the workload they currently have.

Why this type of madness is permitted to occur in California is beyond me.
Because up is down and left is right in California.

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DesertMedic66

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It’s very hard for a hospital to go on divert when pretty much all hospitals in SoCal have crews holding the wall. There are times where I would end up having to drive several hours away to find a hospital without crews holding the wall.
 

DrParasite

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Again, hospitals don't make EMS crews wait for fun. The EMS crew is waiting for a bed to clear. No reasonable person would find that a facility at max capacity can somehow abbreviate the wait time for a bed. By doing what, kicking another patient out to make room for the EMS patient?
Simple solution: get more beds. at one former level 1 trauma center, they used to have beds in every room (and by room, i mean area divided by a curtain). if it got busy, they doubled up. if all the rooms were doubled up, they put beds in the hall ways. this ER had 3 trauma rooms; trauma 1, trauma 2, and shock trauma. Trauma 1 and 2 could hold 4 patients each. Shock trauma was reserved for an unexpected trauma. and if they get hit with multiple traumas, than patient's get relocated (often into the hall ways or they open up other areas for overflow). It's not rocket science, and I can't understand why so many California hospitals can't handle the routine call volume.

Yes, you need to hire more staff, yes, it's a budget issue, but if the patient volume is there, I bet a good attorney could make a good negligence case that the hospital was failing to do their job by staffing appropriately, tying up 911 resources that are unavailable to respond to their primary coverage areas for extended periods of time because despite the obvious need, hospital management will not allocate funding appropriately. Would he win? IDK, but I think he could make a strong case for it.
It’s very hard for a hospital to go on divert when pretty much all hospitals in SoCal have crews holding the wall. There are times where I would end up having to drive several hours away to find a hospital without crews holding the wall.
Sounds like a systematic issue.

Maybe they should take some lessons from their east coast counterparts, who don't have these issues yet have more population to deal with over a smaller area?
 

bakertaylor28

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Ah, now I remember. This guy is the fake lawyer.

You are conflating government funded with government run, first of all. The eight amendment does not apply because no punishment is being carried out by the government. Seeking treatment for psychiatric care is not a punishment issued through the legal system.

You've seemed to lay out a very long explanation of reasonable, which is what the common person would find. Again, hospitals don't make EMS crews wait for fun. The EMS crew is waiting for a bed to clear. No reasonable person would find that a facility at max capacity can somehow abbreviate the wait time for a bed. By doing what, kicking another patient out to make room for the EMS patient?

A psych patient is nothing like a patient in cardiac arrest. One is in immediate and imminent risk of loss of life, the other is not. You even say "within reasonable capability". This means that if no beds are available, you're going to have to wait if you're stable. A non-combative psych patient is stable. By your definition, every abdominal pain or leg pain, which can have a risk of rupturing AAA or DVT turned into PE causing arrest, need to be treated immediately, making every single hospital in the country in violation of federal law since they have people wait in the waiting room.

I really hope you're better at EMS than you are at law.
Government funded and government- run are the same thing for purposes of 1983 complaints and civil rights law. Plus most "County" hospitals are owened in part by the government. eighth amendment law is also not necessarily restricted to criminal punishment- it has been expanded over the years via court decisions to include civil torts involving any case in which a person is placed on involuntary hold via a court order for a non-criminal reason, such as contempt of court and psych holds. The legal test is whether or not the patient is subject to conditions which are tantamount to "incarceration" of any kind. If a facility doesn't have beds available, then the reasonable and prudent thing to do is to refer a patient to a facility that has a bed available within a reasonable amount of time, provided the patient is stable. (which again, under our circumstances, the law doesn't consider our patient "stable" by definition of mental health practice.) Your confusing the mental health definition of "stable" with the ordinary meaning of the terminology, and the two are not the same in the eyes of the law. For purposes of law, a suicidal patient is just as "unstable" as a patient in cardiac arrest- as a suicidal patient can be just as much on death's doorstep without relatively immediate intervention- the difference is that there's quite a bit more time before the crap hits the fan. The question really is "how much" - and the reasonable and prudent person doesn't gamble. Hence waiting 20-30 minutes is reasonable. Waiting 1 to 2 hours is not.
 
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DesertMedic66

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Our hospitals have tried putting beds in hallways but they can only put soo many before it becomes a fire hazard (our hospitals have actually been cited by the fire marshal for it).

The hospitals in my area have several issues. These include a shortage of ER nurses, not enough ER beds, not enough ICU beds, not enough tele-beds. They will have patients wait hours in the ED before an ICU bed opens up. There is also a huge issue with pysch patients in my area. All psych patients have to be medically cleared from the ED and then the ED will work on placement for them which can easily take 3 days. It’s hard to do anything when the whole hospital is literally full with patients.

Are there things that they could change? I’m sure there is. I’m not familiar with how other areas operate and I have no clue about the hospital administrator aspect.
 

bakertaylor28

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Our hospitals have tried putting beds in hallways but they can only put soo many before it becomes a fire hazard (our hospitals have actually been cited by the fire marshal for it).

The hospitals in my area have several issues. These include a shortage of ER nurses, not enough ER beds, not enough ICU beds, not enough tele-beds. They will have patients wait hours in the ED before an ICU bed opens up. There is also a huge issue with pysch patients in my area. All psych patients have to be medically cleared from the ED and then the ED will work on placement for them which can easily take 3 days. It’s hard to do anything when the whole hospital is literally full with patients.

Are there things that they could change? I’m sure there is. I’m not familiar with how other areas operate and I have no clue about the hospital administrator aspect.
This is where they need to be transferring stable patients to other facilities with capability to treat. It's also an area where they need to discharge those ER cases that should be "urgent care" cases- Way too many people clog up the ER with non-life threatening conditions because they can't afford typical treatment. The solution to this is to classify "urgent care" centers as emergency medicine and subject them to the same financial rules. (i.e. that you can't deny a patient for financial reasons.) This, in turn, would rely on proper management of government funds, and congress taking a pay cut. Fat chance in all reality, but that's what needs to happen.
 
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Jim37F

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Back to the original patient, she was a voluntary admit. She voluntarily called 911 herself and requested to be transported due to feeling suicidal, while def stressed, was otherwise completely calm and cooperative and basically just needed a ride....can see why the probably overworked Sheriff's Deputies didn't see a need to add any more paperwork to their dockets...or why the medics felt any need to ALS a calm, stable patient. Here Psych is BLS all day every day until chemical restraints are required, even if physical restraints are required but not chemical restraints, it's still a BLS patient.
(And never mind that up until about hour 3? When the original patient started getting anxious and wanting to get off the gurney did she do anything other than sit on the gurney, yes verbally expressing her unhappiness with the wait... but displayed absolutely zero indications of needing restraints at all....so if you're already upset over a BLS crew waiting that long, how does replacing them with an ALS crew help anything?)

Why this type of madness is permitted to occur in California is beyond me.
If every hospital with a 30+min wait went on diversion, that'd be almost literally every single hospital in my old service area. And that's about a 12 mile radius with almost a dozen hospitals in it, including 2 level 1s, a level 2, a burn center, 2 or 3 Kaisers, multiple STEMI and Stroke receiving centers, is be driving through an hour or more of LAs best traffic to reach one that let that criteria, and so would everyone else, pretty soon I'd be picking up a patient in Compton and driving them to Bakersfield if that was the case!

Yes the solution is more beds and the staff to attend to the patients in them....but that requires funding....and remember many So Cal hospitals in recent years have closed down their ERs due to lack of funding (and no hospital is going to call a stream of non emergency ambulances just to transport out stable patients who've been waiting a while....no insurance is going to pay for the transport of a stable patient simply because they're waiting a while
 

DrParasite

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When the original patient started getting anxious and wanting to get off the gurney did she do anything other than sit on the gurney, yes verbally expressing her unhappiness with the wait... but displayed absolutely zero indications of needing restraints at all....so if you're already upset over a BLS crew waiting that long, how does replacing them with an ALS crew help anything?)
sounds like a good reason to take them off your stretcher, put them in a chair, an have hospital personnel babysit the patient instead of keeping them on the cot, tying up an ambulance crew. And the justification for keeping you guys? did the hospital not have a spare chair for the patient to sit in?
If every hospital with a 30+min wait went on diversion, that'd be almost literally every single hospital in my old service area. And that's about a 12 mile radius with almost a dozen hospitals in it, including 2 level 1s, a level 2, a burn center, 2 or 3 Kaisers, multiple STEMI and Stroke receiving centers, is be driving through an hour or more of LAs best traffic to reach one that let that criteria, and so would everyone else, pretty soon I'd be picking up a patient in Compton and driving them to Bakersfield if that was the case!
blah, blah, blah... not every patient in your level 1 or 2 are traumas, not ever patient in the STEMI or stroke are stemi or stroke patients. all those designations tell me is you have a variety of options for where you can take the critically sick patients, much more than my "we only have one level 1 trauma center in the county" or "we only have 1 burn center in the state."

You know, we have this thing called triage in most of the ERs... if your patient comes in by ambulance, and isn't sick, and can wait, they go sit in the triage area, until they are called. I think I even had one instance where we had a very stable BLS patient, who couldn't sit in a chair, so we put them on a hospital bed, and wheeled the bed to the triage area until they were called
Yes the solution is more beds and the staff to attend to the patients in them....but that requires funding....and remember many So Cal hospitals in recent years have closed down their ERs due to lack of funding (and no hospital is going to call a stream of non emergency ambulances just to transport out stable patients who've been waiting a while....no insurance is going to pay for the transport of a stable patient simply because they're waiting a while
more excuses.... So Cal is not unique in this regard, there are plenty of areas that function better on the east coast, with larger populations, more poverty, and smaller tax bases. You can look up the numbers yourself in my other posts.

The real problem is the ambulance companies accept this and are willing to work as unpaid supplemental hospital staff. As long as they are willing to do it, there is 0 reason the hospitals should be turning down free labor.

I think we have beat this horse to death..... We aren't going to fix the hospital's bed management issue, nor their staffing issue (and the hospital's don't seem to be in any rush to fix it), and if the people on the west coast are ok with holding a wall for several hours, why should anyone else care?
 

Medic27

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My understand is if they are alert and oriented times 3, not making threats or using violence towards others you have to let them go. Personally, I would contact our medical director for advice.
 

wtferick

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I don't trust PD all to often.. they handcuffed our patient to the gurney on scene.. never met us at the ER.
 
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Jim37F

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I don't trust PD all to often.. they handcuffed our patient to the gurney on scene.. never met us at the ER.
One time we had a call where LA Co Sheriff's handcuffed our patient to the gurney (it must've been a fairly big call, I think SWAT got called out? I don't remember, but there were like 50 LEOs there at least.....) and we were going to transport BLS, so the fire crews (NOT LACoFD, but one of the smaller departments McCormick just started transporting for back in January....) were going to clear and go back to station (this was like 11 at night or thereabouts)....but for whatever reason they wanted to wait for us to actually start transporting to leave themselves. Not sure why, but they did. AND they were impatient about it for......reasons? They (Fire) wanted us to hurry up and start transporting, didn't understand why I (I was the driver that shift) was dead set on waiting for someone from Sherrif's to be clearly ready to come with us.....even after I explained how if I drove off then and there I'd be at the hospital with a handcuffed patient and no one to unlock the handcuffs......Naw they'll meet you there......sure they will.....

Well the Deputy who had actually cuffed the guy had walked off, talking to his Sergeant or whatever, but us and fire didn't know where exactly he was, and none of the Deputies seemed to be in a hurry to jump in the back of our rig or even just plain follow in a squad car. If I had let the fire guys talk me into leaving, and if anything would have happened to the patient enroute (you know, the whole reason why they're making us transport in the ambulance vs in one of the Sherrif's squad cars).......(not to mention that we wouldn't have been able to actually transfer the patient off the gurney at the hospital! So yeah, even though we had the patient loaded up, ready to go, even though Fire seemed to have decided they can't clear till I was driving off and were antsy to do just that and kept telling me to do so, I pissed the Capt off by flat out refusing to go anywhere until a Deputy with the handcuff key was firmly seated in the back of the ambulance.
 

wtferick

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One time we had a call where LA Co Sheriff's handcuffed our patient to the gurney (it must've been a fairly big call, I think SWAT got called out? I don't remember, but there were like 50 LEOs there at least.....) and we were going to transport BLS, so the fire crews (NOT LACoFD, but one of the smaller departments McCormick just started transporting for back in January....) were going to clear and go back to station (this was like 11 at night or thereabouts)....but for whatever reason they wanted to wait for us to actually start transporting to leave themselves. Not sure why, but they did. AND they were impatient about it for......reasons? They (Fire) wanted us to hurry up and start transporting, didn't understand why I (I was the driver that shift) was dead set on waiting for someone from Sherrif's to be clearly ready to come with us.....even after I explained how if I drove off then and there I'd be at the hospital with a handcuffed patient and no one to unlock the handcuffs......Naw they'll meet you there......sure they will.....

Well the Deputy who had actually cuffed the guy had walked off, talking to his Sergeant or whatever, but us and fire didn't know where exactly he was, and none of the Deputies seemed to be in a hurry to jump in the back of our rig or even just plain follow in a squad car. If I had let the fire guys talk me into leaving, and if anything would have happened to the patient enroute (you know, the whole reason why they're making us transport in the ambulance vs in one of the Sherrif's squad cars).......(not to mention that we wouldn't have been able to actually transfer the patient off the gurney at the hospital! So yeah, even though we had the patient loaded up, ready to go, even though Fire seemed to have decided they can't clear till I was driving off and were antsy to do just that and kept telling me to do so, I pissed the Capt off by flat out refusing to go anywhere until a Deputy with the handcuff key was firmly seated in the back of the ambulance.
Luckily our crews started having PD take them in stead of us. They would aways come in clutch in the early mornings.
 

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