Treating peds, no immediate consent

[LIFEGUARDAVIDAS]

Hi again, I wanted to have your opinion and experience about providing emergency pre-hospital care to victims and patients who are underage (1, without having a parent, legal guardian or other person responsible for him/her present at the scene.

As a lifeguard, I was trained to asume that, if present, the parent/legal guardian would want me to provide care. -Similar to the legal considerations with an unconcious person (if he/she would be able to ask for help... he/she would and therefore I would have his/her consent to help).

During the PHTLS course, some participants were EMTs, other were EMT-Paramedics, three RNs, an EDT and me. During one of the example cases, involving a kid, each responded according to their agency policies and of course there were many discrepancies.

I am not going to base my response in future cases on the results of your replies, of course, but I am very interested in knowing both: your agency policy, and your personal opinion.

_____________
In my case, last American summer, at the summer camp where I work, one of the campers got his left foot stucked into a hook (caribiner type) between two toes. That happenned at the top of the slide since the hook was one of many that were holding the canvas slide to the wooden platform.

I was called by the lifeguard working the slide and upon my arrival I found out what was happenning. Due to the design of the caribiner and its effect (like a fishing hook), removing it would have made the kid enter into shock and probably left permanent damage. So... since the slide was made of canvas, we were able to cut it around the hook, and in that way transport the camper to the hospital without removing the hook. Both the lifeguards, the camp doctor and the nurse agreed that surgery would be the best way to remove it.

One of the advantages of working in a camp compared with a public beach, is that each camper has a medical history sheet containing (among other stuff) the camper's emergency contact numbers. This wasn't the exception. However, we weren't able to contact the parents on the phone until we were already in the ER. The specialist surgeon was on his way, the kid was really fantastic, and only a minor cut was going to be necessary to extract the hook. BUT... While talking to the kid's mother, the camp doctor found out both parents were doctors. (To make it worse, in "high positions"). Anyways, they wanted the hospital staff to wait for their arrival before treating their son. -One minor detail: they were 5 hrs. away.

Both the camp and the hospital doctors were unable to convince the mother to let them treat her son. 2 hrs. later while the mother was on the road (3hrs. more to reach the hospital) she agreed that they could treat him as long as "before and after" photos of the injury were taken. So after getting a disposable camera, luckily, no permanent damage to the kid's foot was the end of the story.

I was really surprised of the mother's reaction. -Since inspite of the incident, the only thing that could have had left permanent damage was the "temporary refusal of care"!

I know what some of you could think (it's because I don't have kids yet...). But as a doctor's son I can tell you that it's a bad mix: they are the patient's parents and, as doctors, they know all what could go wrong.

Back to the consent issue, on the way to the hospital, I recommended to the camp doctor to contact the camper's parents after he was already getting treated at the hospital. -Precisely to avoid what happenned from happenning. According to my training, the law was on our side, since we were able to asume that the parents would have given us consent. Of course the camp doctor did the opposite.<_<
__________

So if you had similar cases, comment on your agency policy, or just give your opinions... I would be very interested in reading them.

Thank you in advance for reading this!

 

[Ridryder911]

Never assume anything, ( you know the what assume stands for..arse u me).. Sounds like a zealous pompous parent that is worried about cosmetic problems, when in reality probably was no big deal.

However one of your statements concerns me .... recommended to the camp doctor to contact the camper's parents after he was already getting treated at the hospital....In reality, the only time I have seen and even personally will treat a minor without parental consent is when the patient has either a life threatening condition or such case is causing emotional distress.

Of course as you stated most camps have "releases" and allow treatment for simple cases and allow one to have child evaluated at local hospital. Where most E.D. and physicians will wait for the parents for permission to treat unless life threatening occurs. I (in ER ) will attempt verbal consent per phone, then all if fails use the waiver note.

In the field I attempt to make contact with the parent, if there is not one I will make contact with LEO and place child under protective custody. This of course in a situation of non-life threatening, if it is serious "implied consent and law of reasonable man" will apply. Of course technically, they can sue etc.. but, it is far better to err on the patients best behalf.

R/r 911

 

[lfsvr0114]

I agree with ridryder911. Unless it is life threatening or extreme emotional distress, I would attempt to contact parents first. With the popularity of cell phones, it is easier than ever to contact someone. I know I would be upset if they treated or started treating my child without asking first just because they do not want to worry about me saying no.

 

[LIFEGUARDAVIDAS]

R/r 911, sorry about the spelling mistake (assume with only one s), sometimes I think in Spanish and write in English and that's the result.

I agree with both your replies (R/r 911 and Cindy).

Just to clarify, though it wasn't a life-threatening situation, the kid was in great pain and by the time the camp doctor got to reach the kid's parents on the phone (after failing to do so with the phone numbers on his medical history sheet), we were parking outside the ER.

All the "negotiation" process between the hospital staff and the camp doctor with the mother lasted 2 hrs. (The camper really amazed me since he was extremely brave). But I considered then (and still now) unnecessary to have made him go through that without even pain killers. -In spite of the happy ending.

Since after we crossed the ER gate he legally became the hospital doctors responsability, I didn't even make a suggestion (of course) and as a "good boy" did nothing but observing the rest. Obviously, I didn't like their choice (the 2 hour "negotiation") but understood it's probably their policy.

Since then I started to wonder if shouldn't some laws and policies regarding that issue change in the future. It showed me how even if all the help is available, a parent far away can decide if the patient shoud be treated or not.

Of course there are exceptions, like both of you said, when it's a life threatening situation. But my concern is about the cases in the middle: when a band aid is not enough and CPR is not needed yet. -That is why I posted the thread to see the different opinions which might differ from what we have to do.

Thanks again for your interest and helpful info!

Guri

 

[BossyCow]

In all kindness I think part of your lack of understanding might have to do with not having kids of your own. Start with the fact that both parents are doctors, who tend to have a bit of the old Type A personality, add in the parental perogative of 'I know what's best for my kid', sprinkle with a teensy bit of parental paranoia and from the parents' perspective, their child was in danger and they couldn't help him, the immediate parental response is to do what they can, even if its wrong. In this case the only action they could take as parents was to take control. In spite of the pain, which you said the kid was handling well, the child was not going to be damaged by the delay.

Instead of seeing this as a couple of doctors who were allowing their collective egos to put impediments between their child and medical care, you might look at it as a pair of extremely worried parents trying to be part of the solution.

Seeing one of our own as a patient does bizarre things to our brains. Add in the basic instinct of our role as protector of our young and it goes way up from there. The ugly side of this is the parent who feels their wants, beliefs, desires for their kid have been ignored is the most likely to sue. I agree with the ER docs on this one. When you weigh the possible side effects of not calling with those of calling, I think they made the right decision.

 

[Ridryder911]

Legal debate has been on going regarding parental rights and medical treatments for decades.

True, parents have the final decision in regards to treatment of their child, however many are not aware of " exceptions" that makes it legal to treat a minor without prior permission of a parent. Such as of course as life threatening injuries, * injuries that might produce psychological trauma, children of members of the U.S. Armed Forces (military) and those that are currently pregnant.

I have worked at summer camps for several years, we have always had the parents sign a waiver and permission of treatment in any type of event that child might come in contact with. Of course, the statement describes "an attempt will be made if possible and if it does not delay treatment to the child". This prevents the need of calling each time the child needs a "puff of an inhaler" or removal of a fishing barb or tick, the same goes if there is a true emergency. As well a detailed history and immunization and PMHX is attached to the information sheet.

I teach and adhere to the policy to err on the patient's best behalf. As a first responder I would not worry about treating initial care. I will let them deal with at ER, when the parents arrive and do not further care, they can AMA and refuse care. From my experience courts have seemed to side with medical providers in making sure the child is safe.

Good luck,

R/r 911

 

[mxjagracer]

I agree with above. But first, maybe since ive only been a basic for two years or what I dont know. But, No penetrating injury is to be removed, UNLESS it is a DIRECT threat to the airway. The penetrating Item is to be secured in place and transported with the patient. but anyways. when you get that kid to the hospital, he becomes the hospitals pt. obviously its natural to care for the well being of a child but in this case, the injury was minor. Now, if it came to me initiating care during or prior to transport. I would act under implied consent. Any parent who denies the child of initial care, could be found guilty of child abuse. I would have cut the object loose, never considered removing it, (unless that doctor, or nurse, or someone of higher licensing was coming to the hospital with me to transfer care) and transported.

 

[LIFEGUARDAVIDAS]

Hi, I agree with your comment, just to clarify, in the case I mentioned, the impaled object (the caribiner type hook) wasn't removed nor attempted to be removed (neither at the scene nor en route). It was finally surgically removed at the ER 2hrs after the pt's arrival for the already mentioned reasons. Again, just wanted to clarify.

Thank you very much for your interest!

Guri