To AMA or Transport

[wrmedic82]

Thanks for all your comments. They were about what I expected. I will need to fill in further on some details of the call.

Prior to leaving the scene:

I did contact a Supervisor /FTO(whom was in the truck) When I was told that the parents can sign on behalf of the patient. From the way it was told to me according to him that there was some type of exception to the rule that I was never aware of. The willingness of the supervisor to condone this action lead me to believe that this was acceptable. (not saying I agreed with it). The only form of online direction we have is base station physicians at the emergency rooms. Due to policies we have to direct disagreements to the supervisor. Most communication in our system to med control is via email, and voice mail.

The next day I approached the medical records manager concerning this matter to see if I could get a deeper explanation. He told me about what everyone here has said. Needless to say medical control ( EPAB in our system) was promptly advised of the incident and is currently under audit.

There really isn't a good reason as to why we didn't get a BGL. For that I will admit fault, and agree it should have been done.

Thanks again everyone for your comments they are much appreciated

Ok...I had to re-read the initial post before I felt ok to comment. That being said, most of what I have to say has already been said about POA/HC, etc, parents can't legally sign for him blah blah blah. So here's my question...why is his liver chirrotic? I would assume ETOH abuse? If that's the case, is the HX of SZ from DT's from past attempts at quitting? If that's the case, and the bleed is from a head bonk, and this SZ is from DT's, then it was a definate medical emergency that was abandoned. If not...still should have been transported, parent's wishes be damned-cause they can't sign (he's a big boy, no matter what mommy wants to think). Just my thoughts and/or questions.

Patient also had Hx of Hepatitis C. Patient was being seen for psychiatric problems from what Ive been told. No known alcohol abuse specified onscene by therapist, and family onscene. And I agree that he should have been transported, or at least given enough time to return to his baseline mental status and base txp based on the request of the patient.

[Lone Star]

Ok...I had to re-read the initial post before I felt ok to comment. That being said, most of what I have to say has already been said about POA/HC, etc, parents can't legally sign for him blah blah blah. So here's my question...why is his liver chirrotic? I would assume ETOH abuse? If that's the case, is the HX of SZ from DT's from past attempts at quitting? If that's the case, and the bleed is from a head bonk, and this SZ is from DT's, then it was a definate medical emergency that was abandoned. If not...still should have been transported, parent's wishes be damned-cause they can't sign (he's a big boy, no matter what mommy wants to think). Just my thoughts and/or questions.

Thanks for all your comments. They were about what I expected. I will need to fill in further on some details of the call.

Prior to leaving the scene:

I did contact a Supervisor /FTO(whom was in the truck) When I was told that the parents can sign on behalf of the patient. From the way it was told to me according to him that there was some type of exception to the rule that I was never aware of. The willingness of the supervisor to condone this action lead me to believe that this was acceptable. (not saying I agreed with it). The only form of online direction we have is base station physicians at the emergency rooms. Due to policies we have to direct disagreements to the supervisor. Most communication in our system to med control is via email, and voice mail.

The next day I approached the medical records manager concerning this matter to see if I could get a deeper explanation. He told me about what everyone here has said. Needless to say medical control ( EPAB in our system) was promptly advised of the incident and is currently under audit.

There really isn't a good reason as to why we didn't get a BGL. For that I will admit fault, and agree it should have been done.

Thanks again everyone for your comments they are much appreciated

Patient also had Hx of Hepatitis C. Patient was being seen for psychiatric problems from what Ive been told. No known alcohol abuse specified onscene by therapist, and family onscene. And I agree that he should have been transported, or at least given enough time to return to his baseline mental status and base txp based on the request of the patient.

I for one would like to know what this mystical 'exception' to the law is. Since the patient was being seen for psychiatric problems, I would be curious to know how it affected the patients competence in this matter. I'm also curious as to how your local protocols define abandonment, and what they say about refusal of care.

Did the parents have guardianship or conservatorship over the patient? Had the patient been found mentally incompetent in a court of law?

The etiology/pathology of the seizures is irrelevant. The main point is that since care was terminated without the proper transfer of care to someone with an equal or higher licensure, the patient was abandoned. Let's not 'muddy the waters' by throwing etiology/pathology of the seizures, or a discussion of the patients medical history.

[Just Plain Ruff]

This exact call is the reason why any good EMT or Paramedic program will have a reputable attorney give the lecture on medico-legal in class.

That attorney should be one who deals with these types of legal issues on a daily basis.

More than likely this attorney should be one employed or on retainer by a local ambulance service.

It is also one of those calls that proves the need for a more indepth level of instruction than what I was given which was 1 hour of medical legal mumbo jumbo.

If you do not have the basic education on this issue then it is YOUR responsibility to get the education.

The OP is caught between a rock and a hard place where he believes something is Hinky yet both the medic, the stupidvisor and the parents all agree that what happened, which was WRONG, was indeed ok.

If you don't speak up about something then your silence gives tacit approval that you agree and go along with what is happening.

In the end, it's your ASS on the line in court.

[CBEMT]

First off why the first responders have him on 2 liters nasal instead of 10 to 15 lpm nonrebreather is an issue by itself.

I didn't know a postictal state could be resolved with high flow oxygen.

Read the OP again [hint- the patient presentation specifically] and come back and explain why this patient needs a non-rebreather.

[wrmedic82]

I for one would like to know what this mystical 'exception' to the law is. Since the patient was being seen for psychiatric problems, I would be curious to know how it affected the patients competence in this matter. I'm also curious as to how your local protocols define abandonment, and what they say about refusal of care.

Did the parents have guardianship or conservatorship over the patient? Had the patient been found mentally incompetent in a court of law?

The etiology/pathology of the seizures is irrelevant. The main point is that since care was terminated without the proper transfer of care to someone with an equal or higher licensure, the patient was abandoned. Let's not 'muddy the waters' by throwing etiology/pathology of the seizures, or a discussion of the patients medical history.

Couple things:

To answer your first question I don't know hence why this topic was brought up here. The whole point of this discussion is so I can see if there was something I missed. I have never heard of anything like this.

Second, if your read the beginning of the discussion I have already specified that no durable POA was presented by the parents on scene.

Third you are correct, etiology/ pathology is irrelevant. But again if you read the other posts you would see I was merely filling in the blanks as far as questions being asked in the discussion.

I will say this though. The real issue is not that the patient was turned over to family. But rather how it was done. That is where my problem lies. I know this is going to stir up a hornets nest so let me explain my side, and I will try to play medic advocate.

First and foremost I wouldn't have had the parents sign without a durable medical POA. That's something Ive known since I was in basic school. that was covered also in paramedic school which Im still currently in.

Second I would have personally conferred with the patient's neurologist. Getting his knowledge of the patient's Hx. Then provide the doctor with information gathered on scene, concerns, and any other pertinent information. If the doctor states that transport is still unnecessary at that point, then I would document the conversation in the chart including the physicians name, and DEA number. That way if it did come up in a legal setting it is documented, thus shifting liability to the neurologist.

Third if the later was not done. I would have at least waited for the patient to return to their baseline. Then advise the patient of risks and benefits of being txp. Then its up to the patient, and they can sign for themselves. Now Im not advocating doing this as it can take some time on scene for this to happen obviously. However legally would have been right. Reason it is because the patient that knows their own medical hx, what has happened, and is AOx4 which makes them legally competent. The law the places this under expressed consent. That way issues with all others involved are settled w/o conflict.

I am sure that the medic was thinking " well the parents and the doc don't want him to be transported so it would be ok to leave the patient with the parents".I'm also sure he meant well when doing what he did. Mom also stated she is a RN so the patient wouldn't be in unknowledgeable hands. Now am I saying this line of thinking is right?Can be if handled correctly as specified earlier.

Last I feel like I am beating a dead horse when I say I have contacted the medic involved, a supervisor, and our medical control (EPAB). All parties have been contacted, and know of the situation. Yes there was a delay in contacting EPAB. That I have no control over. It would be crazy to pull a emergency physician taking care of patients to get on the radio to handle a medico legal dispute.. All the physician is going to do is say contact your medical director. ( yes this has been done before, just different issue )

Lets keep this discussion civil.

Edited April 22, 2009 by wrmedic82

[ERDoc]

wrmedic, just a few things to add. It is a great idea to talk with the neurologist so that you can get more history on the guy. In a court you will hang if you say that the responsibility has been shifted to him. He was on the phone and did not have contact with the pt. He can offer his advice but he is in no position to take any responsibility. Don't allowed yourself to be lulled into a false sense of security if some unknown doctor says it's okay not to transport over the phone. This is a minor point, but when you get his info, get his license number. His DEA number won't be helpful. It also does not matter what his mother does (assuming she can prove she is an RN). She is not acting as an RN in this capacity and therefore care cannot be turned over to her. The only one in this case that can RMA is the pt and he is in no position to do so. It takes a little more than being A&OX3/4 to be able to refuse care. The person has to have the capacity to do so, which means that they must be able to fully understand what is going on and what the consequences of signing RMA mean. There are plenty of people who are A&O but do not have the capacity to make their own decisions. Always contact your medical control if there is a question, it is the reason they are there. Don't worry about taking them away from other pts. If they are your medical control it is their job to help you deal with issues in the field. If they don't you need a better system in place.

[HERBIE1]

Rules and regulations are fine and obviously we need to always do what's best for our patients and CYA. Problem is, as anyone who's been in this business for more than a day or 2, they KNOW not everything is black and white. My issue here is with those ignoring the neuro doc on the phone. Yes, there is nothing to ensure that he was really the patient's doctor or even a doctor at all but I'm the most paranoid, cynical guy around. If I am speaking with someone who sounds like a doctor, is familiar with the patient, and is giving appropriate advice, I am NOT going to dismiss his counsel out of hand. Get your medical control involved, explain the convsersation you had with the neuro guy, explain the patient's condition, and leave it up to them.

I will never forget a lecture I had years ago by the medical director of our local epilepsy foundation who emphasized many times that most patients who have seizures, with a known history of same-do NOT need to be transported. This went against everything our system preaches and we tried to explain this problem to the guy. We agrued with the guy- about level of consciousness, etc. He didn't change his stance, nor did we. Again, it sounds great on paper, but you need to balance what's best for the patient, what is proper protocol, and the details of each particular situation. If this kid has a complicated medical history, I would be far more likely to simply take the patient, but I was not there.

Problem is, now we have a pissing contest between the family, the doctor, and your medical control. In my experience, most times medical control will not go against the wishes of the attending physician- regardless of what our protocol says. Yes, we've all been taught that unless the doc takes over treatment, signs your form to take responsibility, AND accompanies the patient, they can't assume responsibility. Has anyone provided treatment, directed by medical control, that is NOT part of our protocol? Many times, I have given Benadryl for a dystonic reaction yet we have no established protocols for such a problem.

In reality, this neurologist is an MD, with far more training than we have, they have personal knowledge of the patient and their history, and if they "suggest" a course of treatment, we would be hard pressed to disagree with that and have it hold up in a court of law- even with medical control. Politics and turf wars complicate our jobs.

Tough situation- and unfortunately, unless you plan on leaving the business, it won't be the last judgment call you will be forced to make.

Isn't medicine fun??

[Lone Star]

wrmedic82,

By no means am I trying to make this anything less than a civil discussion, nor am I 'beating a dead horse' here.

It's unfortunate that you're in this position, I'm just trying to see things from all angles.

The reason I asked for more information on this 'mysterious exception' was because I was under the impression that you had spoken to the supervisor that told you about it. I was just curious as to his 'explanation'.

ERDoc makes some valid points. I especially have to agree with the statement about it being the medical director's job to deal with these types of issues.

The etiology/pathology statement wasn't directed at you personally. I could see that you were merely responding to the questions being presented. I only mentioned that to keep the thread on topic.

Herbie,

Under the current structure of EMS systems, we are a designated agent of the medical director, and our authority to practice is an extension of their license. In this case, even though the 'neurologist is an MD with far more training than we have', I'm sure that the medical director would have the final say; since it is their license we're working under.

[ambodriver]

We responded to a call at a therapist office for a 35/m who had a seizure. Upon our arrival at the patient's side. The patient was found sitting in a chair receiving supplemental oxygen via NC 2 L/min from our firefighter first responders. The patients parents were onscene when we arrived, and did not want their son transported to the emergency room. I personally advised the mother about the needs, risks, and benefits of going to the hospital. Mom didnt budge. Meanwhile the patient is still comming around but still obviously post ictle( not answering all questions appropriatelu). Vital signs were HR 90, RR 20, BP 130/80, SpO2 97% eyes were initially 3mm PEARL, unknown AO status as my partner who was running the show didnt care to find out .PHx seizures, brain bleed secondary to a seizure, cirrhosis of the liver. We did not obtain blood glucose. Parents state that they will call the patient's neurologist to get his opinion. Mom goes into the therapists office and makes a phone call. Shortly after mom returns, and says the neurologist said no that the patient did not need to be transported. No verification was done on my partners end ( as he was running the call) Parents did not have a medical power of attorney with them. My partner had the parents signs AMA, and released the patient to the care of the parents. While we were assisting the patient into the parents car, I noticed that the patients pupils were pinging, and patient began to exhibit lethargy.

Now a couple things didn't set right with me, and I want to see if maybe Im being too hypercritical or if Im right to not feel right about this.

1.If the patient is an adult, normally AOx4 confirmed by parents, and is confused due to seizure. Can patient be legally turned over to parents in the absence of medical POA??

2. If parents talk to patient's physician concerning txp, is it prudent for the medic onscene to make contact with the physician?

3. With the lack of medical POA, unconfirmed request by patient's physician, and the patient obviously confused. Would you have made transport decision for the patient on the side of the family's request or the side of the patient.

The responses I got from the medic I was working with was that the decision was on the side of the patient, and that the parents can sign on behalf of the patient, and hold up legally. (not sure I agree with that, but I dont know)

What would ya'll do?

What insight do ya'll have to offer?

Without a chem anda mental status this could not be a refusal. Their parents are not the ones making the decision in this case. I hope it doesn't come back to bite your ass. The doc on scene is not your medical director and his input about transport is meaningless.

[Arizonaffcep]

Without a chem anda mental status this could not be a refusal. Their parents are not the ones making the decision in this case. I hope it doesn't come back to bite your ass. The doc on scene is not your medical director and his input about transport is meaningless.

I disagree. While certainly not the end all, taken in consideration with consultation with YOUR medical director, then it is a good consideration. After all, from all the practictioners who are tending to this patient, they are the most knowlegable about the Pt.