Would you have transported this patient?

[medicdan]

I'm sorry if I'm not seeing the scenario clearly, but a blaring question. WHY are we transporting this patient to a hospital? If there is no change to the patient's condition (this agitation, etc is NOT new), no other symptoms, expect, perhaps that the benzos the hospital prescribed before discharge are wearing off, why are we going to a hospital? As part of the admitting process at the assisted living, a treating MD (whether on site or not) should have reviewed the discharge med list (and summary page 2), and approved meds for admin until he or she can personally examine the patient, and among those meds, especially for a patient on a conservatorship, needs to be a benzo.

If the patient is comfortably in their room, and the facility has the staff to "manage" that drug admin, why are we transporting? What benefit is the patient receiving?

 

[CAOX3]

If facilities that routinely take care of psychatric patients are routinely calling for police, then those facilities should absolutely not be taking care of patients with psychatric conditions. What's next, elementry schools calling police because a child threw a temper tantrum?

Oh, as far as the test to be a police officer? If you don't want to work with psychiatric patients, don't take a test to be a medical professional.

You still haven't mentioned the value added of having a police officer on scene.

I say this with the utmost respect because I value your opinions.

Its quite simple actually, when violence is introduced to the situation it changes the rules sick or not.

Most psych patients do not require a police response but with history of violence with staff members, this guy isnt going to have a problem taking a swing at you the cop or anyone else for that matter.

So you speak with him, he sits on the stretcher then through the sickness in his mind he believes your taking him somewhere he doesnt want to go. Its not his fault he doesnt recognise your title as EMT and your sole responsability is his care and safety, he isnt ratrionale it isnt him its his sickness. He then uses you and your partner as speed bumps on his way back into the free world. Now you have released a violent person into the community who now believes everyone that approaches him is intent on hurting him or taking him somewhere he doesnt want to go. So now you need twenty cops to search for this guy before he hurts an innocent person, when one would have would have sufficed.

You cant reason with a brain sick person, he's probably been off his meds for weeks, he'll play you like a piano to get what he wants. Ive seen it a hundred times these people can be masters at manipulation. We dont take those chances.

I admit the scenario could be far fetched or it couldnt be. I dont want you or anyone else injured in a situation that was completely avoidable.

Nine out of ten times everything goes smoothly, its the one time it doesnt that gets you in the fishwrap and everyone needs to iron their dress uniform.

 

[JPINFV]

So you speak with him, he sits on the stretcher then through the sickness in his mind he believes your taking him somewhere he doesnt want to go. Its not his fault he doesnt recognise your title as EMT and your sole responsability is his care and safety, he isnt ratrionale it isnt him its his sickness. He then uses you and your partner as speed bumps on his way back into the free world. Now you have released a violent person into the community who now believes everyone that approaches him is intent on hurting him or taking him somewhere he doesnt want to go. So now you need twenty cops to search for this guy before he hurts an innocent person, when one would have would have sufficed.

I'm confused. Do you not carry restraints where you worked? I've always had a pair of commercial leather wrist restraints and commercial nylon ankle restraints on every ambulance I've worked on and I'm definitely not saying that they shouldn't be used in this situation.

You cant reason with a brain sick person, he's probably been off his meds for weeks, he'll play you like a piano to get what he wants. Ive seen it a hundred times these people can be masters at manipulation. We dont take those chances.

You don't know any of those are true for this patient. You don't know what can and can't be reasoned with this patient, You don't know how compliant the patient is with his medication.

I admit the scenario could be far fetched or it couldnt be. I dont want you or anyone else injured in a situation that was completely avoidable.

Nine out of ten times everything goes smoothly, its the one time it doesnt that gets you in the fishwrap and everyone needs to iron their dress uniform.

I don't want to see anyone get injured either and that includes the patient. I also believe that these are patients and that, while sometimes you can't, it is truly amazing what can be accomplished by calming talking with a patient while showing respect. Quite often patients know that they are sick, but you won't know anything about the patient if you're staged 2 blocks away from a healthcare facility waiting for police.

 

[CAOX3]

I have restraints and they can be used after the cops have subdued him.

There not really usefull if it takes a battle royal to get him in them, risking injury to us and him.

My job is also to assure safety for myself, my partner and the patient.

Im assuming this isnt a 911 call as there probably would have been cops there when the dispatcher reported the violence.

I wouldnt be staged down the the street but he can stay calm in his room until the police arrived and I agree a police presence could elevate the situation, its a neccesary evil.

Pt is Dx with Schizophrenia with a Hx of paranoid delusions.

You are right, I dont know how compliant he is on his meds and I dont know how rationale he is, but now that violence has been introduced Im a lot less likely to attempt to reason with him.

He has a history and he has already resorted to violence once, it really isnt worth the risk.

My reasoning is Im not taking a cop off the street for a bullcrap complaint, I believe its warranted.

 

[Veneficus]

So I just skimmed through these but...

If the facility is requesting transport to a hospital, I am not sure what the hospital is going to do for the patient, certainly it will not benefit the patient.

Oh well, first rule of medicine, punt on first down, right?

I see lots of opinions on less than lethal force, but I didn't see one suggestion to call an ALS rig with some drugs if the facility can't provide it.

I try not to get the cops involved whenever possible. You know, they have things to do too and their very presence usually upsets people.

If the guy is willing to be calm then I would take him, add a few seatbelts incase he flips, and i haven't worked bls since BC, but on an als rig if he gets frisky, give him some benzo and call it a day.

I try not to use physical restraints unless there are enough people to properly engage in that kind of behavior.

Sounds like in this case, somebody is going to have to be called for some extra people, it is just a matter of how escalation is chosen.

 

[usalsfyre]

Oh well, first rule of medicine, punt on first down, right?

That may be the quote of the day...

For those that wish to ge LE involved, what's the plan on their arrival? Most LE agencies in my experince are going to be reluctanct to transport this patient if he is not acting out on their arrival, especially considering they did not witness the assaults and the employees will have to file complaints which is (again in my experince) unlikely. I'm going to be extremely hesitant to restrain this patient in anything but medically approved restraints unless LE is willing to ride with me (unlikely). So we're left with either agitating this guy because LE is there or LE having a stern talk about behaving with the now non-violent individual and stating everything is safe. Neither of which does ANYTHING to ensure our safety when rolling down the road at 70mph in an 8x14 box filled with sharp and heavy objects.

Here's my plan. Have a chat with the patient about how you're gonna get him out of this place, which he's obviously not a fan of. Ask him to sit on the stretcher, and belt him in place. Have staff ready to assist, and try to talk him into restraints willingly, as a condition of exiting the facility. If not, restrain(remember one to two for each limb), and see how he reacts after the fighting phase is over. If he calms down, we're gonna take a nice, quiet ride up to the ED. If he remains agitated, call for ALS back-up to sedate and avoid the nastiness that accompanies agitation and fighting restraints.

 

[spike91]

Not doing ANYTHING until PD/SO is on scene. Would start interacting with the pt with PD/SO supervision, see how PT responds to our presence and the presence of the officer, then make a tx decision.

 

[EMS/LEO505]

Is NM the only state with a good old fashion asylum?

Have the orderlies with their psychiatric drugs dope him up and haul him off to the sticks lol

 

[firecoins]

If the patient is violent and the staff of the facility is unable to handle the situation, yes the police are warrented. More than 1 will be needed.

If the patient is not violent, we will try to coerce them on to the cot peacefully and get them medicated for the trip. I don't need them becoming violent during the trip. I will most likely restrain them in some manner.

If the patient becomes violent enroute and is beyong my control, I will get help from cops.

 

[Shishkabob]

So... those of you so intent on waiting for PD--- have you ever really dealt with a psych (or high) patient, or are your company's protocols with restraints THAT archaic?


Most people act on the up and up the moment they see PD, but PD won't travel in the back of the rig with us unless they see combativeness. The moment the cops are gone, the patient will be aggressive again. Kinda useless to call PD out for the non-help.



We routinely transport from a psych hospital to a regular hospital, literally separated by a parking lot and 30 second drive. One aggressive move, and the patient is put down, restrained with limb restraints and 5x cot belts, and sedated with Valium and/or Haldol before they know what happened. I don't take my safety lightly, but I'm also not afraid to go hands on to make sure I DO stay safe.

 

[medicdan]

I'm sorry, I think I, the OP and Vene are all preaching the same thing. WHY are we transporting this patient to the hospital, if there is no acute NEW condition. Why can't we determine whether the facility can administer benzos, or bring the care to the patient, given the risks associated with bringing the patient to the care?

 

[firecoins]

So... those of you so intent on waiting for PD--- have you ever really dealt with a psych (or high) patient, or are your company's protocols with restraints THAT archaic?

I have dealt with plenty of Psychs. If the patient is violent beyond the facility's ability to handle it, why are you not waiting for cops? Its pretty archaic to think I am going to handle it myself.

Most people act on the up and up the moment they see PD, but PD won't travel in the back of the rig with us unless they see combativeness. The moment the cops are gone, the patient will be aggressive again. Kinda useless to call PD out for the non-help.

I am wearing an official looking uniform and I am putting him on a stretcher. He is going to be so cooperative for me. EMS has never been mistaken for cops.

If he isn't violent like when you describe when the cops aren't there. why would you need to cops?

We routinely transport from a psych hospital to a regular hospital, literally separated by a parking lot and 30 second drive. One aggressive move, and the patient is put down, restrained with limb restraints and 5x cot belts, and sedated with Valium and/or Haldol before they know what happened. I don't take my safety lightly, but I'm also not afraid to go hands on to make sure I DO stay safe.

I transport psych all the time. You don't need cops for medicated patients.

 

[JPINFV]

Is NM the only state with a good old fashion asylum?

Have the orderlies with their psychiatric drugs dope him up and haul him off to the sticks lol

Nope. Southern California has a bunch of stand-alone psychiatric hospitals, a bunch of hospitals have various amount of psychiatry units (some have everything, some just do adults, some just do geriatrics), and a handful of skilled nursing facilities also have locked psychiatric units.

 

[Veneficus]

I think there are several issues at hand.

The first is: Is the facility actually equipped to handle psych patients?

I have been to a few psych at SNFs where the patient was determined to not be capable of living alone. When the patient was on meds as prescribed and the staff were generally tolerant, that works out fine.

Having said that, all it takes is for one person to decide the pt "will cooperate or else" or the staff gets too literal with the rules and takes away somebody's food tray at a certain time, and the next thing you know you have a previously passive angry combative psych which is now beyond the ability of the facility.

The facility then decides anywhere (like the ED) is better for them. But the ED is not really useful to psych patients. It is usually a busy place, where no rest can be had, constant 1:1 supervision, more stringent rules, lights on most of the time, and highly uncomfortable. They misbehave after 20 hours in the ED, all restraints and all manner of suppression come about.

How is that supposed to deescalate anyone?

There aren't a whole lot of long term psych beds anywhere. Once you find a place that will sit on these people for a 72 hour cool down, then what? Back to the original or similar facility to replay the event?

anecdote: I once had a psych patient assault a LPN at his facility because he told her he didn't like fish and she brought him a fish dinner and refused to give him anything else.

Sure, he was restrained by us, sedated, an taken to the ED. The LPN was transported by another squad with 3 missing teeth and a broken nose. She demanded to file a report and press charges, which PD did, but then the prosecutor threw it out. He was a known psych patient commited to long term care. What is the point of even trying to put him through the criminal justice system? Ultimately no charges filed and all over a fish dinner.

Sometimes when PD gets involved it turns into a "yes you are!" "no I am not!" confrontation. All kinds of trouble can start there.

I suggest caution from any provider who feels that an authoritative approach to EMS is called for. It is a big grey patch of unstable ground.

For certain be safe, but before deciding to call out the cavalry, maybe have a look see at what is going on.

I think many suburban and small city providers are a little too quick to call the cops. The purpose of the police is not to baby sit EMS providers who want everyone beat down, tazered, and handcuffed to declare all safe.

Finally always make sure you have an escape route.

 

[Sassafras]

Scene safety first and foremost. Sure he's just been discharged from an accute care facility to this one, but they are obviously not prepared to deal with whatever his issues are. Secondly, schizophrenia is VERY manageable with medication. If he's still acting violent then obviously his medication is very wrong. He needs to go back for treatment since what he's got isn't working. That being the case, I know first hand schizophrenics can be wonderful people, but when bottoming out they are not safe in the slightest. There's no way in hell I'm going into a patient's room knowing the history of this guy. I will definitely contact PD, talk when they have determined he is calm enough to discuss restraints, and because our protocols in our region mandate no restraints without PD involved guess who's riding to the hospital with me.

My last job dealt with behavioral issues all the time. I know if it came to where I could not handle the situation and called 911 for a client in crisis PD is sent as well. We all take a ride and drop them off at a legitimate psychiatric ward. Not an assisted living home.

I plan on going home to my children in one peice tonight. I'm not taking even the slightest risk if at all possible with a potentially hostile situation.

The paramedic who taught our class is married to a LEO and she pressed this ideal of scene safety at all times. Bring PD if you feel you need it, don't go in until it's safe. Improperly medicated schizophrenic is not stable enough for me to feel safe.

 

[JPINFV]

I have dealt with plenty of Psychs. If the patient is violent beyond the facility's ability to handle it, why are you not waiting for cops? Its pretty archaic to think I am going to handle it myself.

Except it's not -just- you. It's you, your partner, and facility staff. You aren't going to get a swat team of officers to put the patient on the gurney.

I am wearing an official looking uniform and I am putting him on a stretcher. He is going to be so cooperative for me. EMS has never been mistaken for cops.

However if the patient is regularly using ambulance transport, it's a little hard to accept the assumption that the patient will jump directly to, "dark uniform, must be police."

 

[SanDiegoEmt7]

Being from the SD area, I think there is some confusion as to this facility, which is creating the issues.

A true psych facility (of which there are about 5, not including hospitals) in SD would medicate the patient and never request transport, unless the patient has just arrived and they want to get a medical clearance.

It sounds like this gentleman was in a facility with inadequate level of care, an assisted living is not a psych facility just because it admitted some psych patients. The assisted living had a patient that got too difficult for them and they just want to turf him for a while. What were you going to tell the MICN when you made report. "we have a 22yo male, c/c disturbance in behavior, he's a/ox3, no SI/SA, he's just angry". Also, I'm assuming that the OP works for a private company and that this call never got the chance to have PD considered.

I believe this should have PD involved from the get go.

 

[Bullets]

Do you guys really get PD on every call for service?

For those preaching scene safety, what do you do if he complies half way to the hospital, then freaks?

If the staff is willing to help and have 4-point restraints, get the biggest orderlies around and lets get cracking. i feel safe dealing with an EDP if i have backup.

 

[adamjh3]

First off, I apoligize for not being able to get a more thorough reply in as I'm on my phone at work and quoting is a pain, I'll have a more detailed follow-up to this when I get home.

I believe I may have described the facility poorly. The facility was Alpine Special Care which since last night I have learned is a psych rehabilitation center.

I apoligize for the confusion, I was mislead on what exactly the facility was.

I work for a private company, PD never had a chance to get involved.

We ended up transporting the Pt in 4 point velcro restraints with no PD involvement without incident. The discussion here and a follow up with my partner today confirmed for me the belief that we made the right decision.

During transport he was completely compliant with us and understood why he was being transported, though it seemed he didn't recall that he had the violent outburst. It's amazing what calm confidence and communication with the patient can accomplish.

When the nurse at the hospital asked him why he was back he replied it was because "People were talking s***." He seemed aggravated by the appearance of uniformed security staff at the hospital. I didn't hear much else though, we did our turnover and left fairly quickly as there was a call holding for us.

Bullets, you make a very good point. Having a safe scene to start, doesn't mean it can't become unsafe.

I genuinely appreciate and enjoy the discussion that has occured in this thread, it has been very insightful and thought-provoking.

 

[JPINFV]

I believe I may have described the facility poorly. The facility was Alpine Special Care which since last night I have learned is a psych rehabilitation center.

From the website linked. "Alpine Special Treatment Center is a locked mental health rehabilitation and transitional care facility. We provide care to voluntary and involuntary adults with acute psychiatric symptoms and those suffering from co-occurring disorders."

So it's a specialty care facility. They may not want to do chemical restraints, but they definitely have the staff and training to assist with putting the patient into physical restraints.

We ended up transporting the Pt in 4 point velcro restraints with no PD involvement without incident. The discussion here and a follow up with my partner today confirmed for me the belief that we made the right decision.

During transport he was completely compliant with us and understood why he was being transported, though it seemed he didn't recall that he had the violent outburst. It's amazing what calm confidence and communication with the patient can accomplish.

Quoted for truth, emphasis, +500 on the bolded, and the American Way.

When the nurse at the hospital asked him why he was back he replied it was because "People were talking s***." He seemed aggravated by the appearance of uniformed security staff at the hospital. I didn't hear much else though, we did our turnover and left fairly quickly as there was a call holding for us.

Imagine his response over uniformed and armed police being on scene.