Should We Have Transported...?

[HERBIE1]

Since the others covered it so well already...all I have left to ask is this:

Where does he work and why was it not shocking to you when he said he would be proceeding to work after drinking that much vodka and pill chasing?

Probably a US Congressman. LOL:whistle:

[funkytomtom]

he has a job where I would be surprised if half the employees weren't loaded on pills and vodka (yes, seriously). maybe he was a congressman

[ERDoc]

http://www.newsday.com/long-island/nassau/woman-left-on-operating-table-sues-north-shore-hospital-1.1470530

Combining 2 threads here, but this just shows that anyone can get sued for anything. The anesthesiologists and orthos who did their job and completed the first surgery are being named.

[Velasquez EMT]

The patient admitted to taking 20 Aspirin, that should have been enough to transport. When all else fails, you should have "medical control" that you can call (local ER Doc if nothing else)to assist you in making the correct decision. In the future, involve a doctor.

Based on the information I just read, I definitely would have transported this pt. Understanding that this pt was intoxicated and mentally impaired, should be reason enough to get him transported. Also, this pt admitted to taking an excessive amount of ASA, which clearly shows intent to harm ones self. If a pt shows signs of threat to others or himself, that is usually a sign that the pt is in need of care. My advice if this kind of situation presents itself again, is DOCUMENTATION. We open ourselves up to lawsuits almost on a daily basis. If you document, document, document, such information as in this case, you should have a leg to stand on. Being that I was not there, I can only offer this as opinion.

[Fox800]

Agree with the majority of previous posters. You should have transported. In my service, this would fall under implied consent and the pt. would have been unable to refuse transport due to suicidal gesturing/demonstrated self harm because he took 20 aspirin + ETOH. My agency/medical director has a very low threshold for implied consent when it comes to suicidal patients.

[DwayneEMTP]

Agree with the majority of previous posters. You should have transported. In my service, this would fall under implied consent and the pt. would have been unable to refuse transport due to suicidal gesturing/demonstrated self harm because he took 20 aspirin + ETOH. My agency/medical director has a very low threshold for implied consent when it comes to suicidal patients.

Yeah, in fact it sounds like they've taken the spirit of implied consent and simply made up a new definition out of whole cloth.

Unless I've forgotten how this went, it sounds to me like this pt is AAOx 4. How does implied consent come into play concerning a pt that is able to continue to coherently advocate for themselves? Do I WANT to transport this patient? Of course. Do I have the right to take an alert and oriented pt against their will? Absolutely not. I would get the pd involved, if that didn't work I'd request a pd supervisor while I contacted medical control, and do what I could to bring the entire world raining down on his head. But, you know what? If all of that fails to put this pt in pd custody, he's staying home. It really is as simple as that. I'll run on him again when he's less responsive or dead. It's a shame, but it's also his right at this point.

I ran on an 86 y/o woman tonight after a fall. Large abrasion center of her forehead, nose obviously fractured with anatomy pushed a few mm to the R, mushy to palp, significant swelling at apex and continuing up into medial/superior orbits bilat, slight drips of clear fluid from R nare, airway patent, including nasal passage, AAO x 4, PERRL at 3mm, eyes tracking properly to all fields, yadda, yadda. She refuses transport, no way to shake her. I even bring a mirror from her bedroom so she can see how screwed up her face is. I finally call her son, a priest, to help convince her. His response is, "A broken nose isn't the end of the world, she's had one before, she falls almost every week." Pt lives alone. Police called, ER physician notified. Police refuse to place her in custody, physician states that pt is able to refuse though explains to pt and son that he and I both believe that there is a significant chance of a cranial vault fracture currently and many possible current/future occult live/limb threatening pathologies possible if not likely. Son refuses.

She is home now, asleep, or dead, and I await my call back to either treat or pronounce her. Does it suck? Oh yeah, I was fucking livid! But you know what? She has the right to determine the course of her own life, either safely, or not. Tonight she believed she did right, I believe she made a terribly foolish and dangerous decision.

So, it sounds to me that what about 90% of these posts are saying is that I should have followed a logic tree similar to, "I've told her that this injury can, and may, kill her. She has decided that she finds that risk acceptable. Therefore she is purposely endangering her life. Purposely doing so is akin to suicide, so this woman is suicidal. Because she's now suicidal I have the right to throw her on my cot, tie her down and force her to the hospital for evaluation based on the fact that a suicidal pt must be altered and altered people can't advocate for themselves.' Etc, etc, etc.

Doesn't this seem like long, long, long bullshit path to follow to attempt to treat someone against their will? I transported 99.1% of my patients this year, so it's not about wanting to dump anyone. It's simply a strongly held belief in a persons right not to have medical/psychological treatments physically forced upon them if they are able to show that they understand their situation and are biologically sound/mentally able to advocate for themselves. Do I think that true suicide attempts fit into that category? I do not. Do I believe that 95% of reported suicide attempts do? I do. Can I tell the difference? Fuck no, mistakes are going to be made. But that sometimes is going to happen in a free society. Or so I believe.

So, in case I got to wandering, it's late at the end of a long week, NO, if the police would not put this pt in custody, after my righteously aggressive, very best attempts to convince them to do otherwise, I would not have taken this pt against his will.

Dwayne

[armymedic571]

Dwayne. Plus 1 for a proper thought tree (your words) haha

[Velasquez EMT]

Yeah, in fact it sounds like they've taken the spirit of implied consent and simply made up a new definition out of whole cloth.

Unless I've forgotten how this went, it sounds to me like this pt is AAOx 4. How does implied consent come into play concerning a pt that is able to continue to coherently advocate for themselves? Do I WANT to transport this patient? Of course. Do I have the right to take an alert and oriented pt against their will? Absolutely not. I would get the pd involved, if that didn't work I'd request a pd supervisor while I contacted medical control, and do what I could to bring the entire world raining down on his head. But, you know what? If all of that fails to put this pt in pd custody, he's staying home. It really is as simple as that. I'll run on him again when he's less responsive or dead. It's a shame, but it's also his right at this point.

I ran on an 86 y/o woman tonight after a fall. Large abrasion center of her forehead, nose obviously fractured with anatomy pushed a few mm to the R, mushy to palp, significant swelling at apex and continuing up into medial/superior orbits bilat, slight drips of clear fluid from R nare, airway patent, including nasal passage, AAO x 4, PERRL at 3mm, eyes tracking properly to all fields, yadda, yadda. She refuses transport, no way to shake her. I even bring a mirror from her bedroom so she can see how screwed up her face is. I finally call her son, a priest, to help convince her. His response is, "A broken nose isn't the end of the world, she's had one before, she falls almost every week." Pt lives alone. Police called, ER physician notified. Police refuse to place her in custody, physician states that pt is able to refuse though explains to pt and son that he and I both believe that there is a significant chance of a cranial vault fracture currently and many possible current/future occult live/limb threatening pathologies possible if not likely. Son refuses.

She is home now, asleep, or dead, and I await my call back to either treat or pronounce her. Does it suck? Oh yeah, I was fucking livid! But you know what? She has the right to determine the course of her own life, either safely, or not. Tonight she believed she did right, I believe she made a terribly foolish and dangerous decision.

So, it sounds to me that what about 90% of these posts are saying is that I should have followed a logic tree similar to, "I've told her that this injury can, and may, kill her. She has decided that she finds that risk acceptable. Therefore she is purposely endangering her life. Purposely doing so is akin to suicide, so this woman is suicidal. Because she's now suicidal I have the right to throw her on my cot, tie her down and force her to the hospital for evaluation based on the fact that a suicidal pt must be altered and altered people can't advocate for themselves.' Etc, etc, etc.

Doesn't this seem like long, long, long bullshit path to follow to attempt to treat someone against their will? I transported 99.1% of my patients this year, so it's not about wanting to dump anyone. It's simply a strongly held belief in a persons right not to have medical/psychological treatments physically forced upon them if they are able to show that they understand their situation and are biologically sound/mentally able to advocate for themselves. Do I think that true suicide attempts fit into that category? I do not. Do I believe that 95% of reported suicide attempts do? I do. Can I tell the difference? Fuck no, mistakes are going to be made. But that sometimes is going to happen in a free society. Or so I believe.

So, in case I got to wandering, it's late at the end of a long week, NO, if the police would not put this pt in custody, after my righteously aggressive, very best attempts to convince them to do otherwise, I would not have taken this pt against his will.

Dwayne

[JPINFV]

Yeah, in fact it sounds like they've taken the spirit of implied consent and simply made up a new definition out of whole cloth.

Unless I've forgotten how this went, it sounds to me like this pt is AAOx 4. How does implied consent come into play concerning a pt that is able to continue to coherently advocate for themselves? Do I WANT to transport this patient? Of course. Do I have the right to take an alert and oriented pt against their will? Absolutely not. I would get the pd involved, if that didn't work I'd request a pd supervisor while I contacted medical control, and do what I could to bring the entire world raining down on his head. But, you know what? If all of that fails to put this pt in pd custody, he's staying home. It really is as simple as that. I'll run on him again when he's less responsive or dead. It's a shame, but it's also his right at this point.

I ran on an 86 y/o woman tonight after a fall. Large abrasion center of her forehead, nose obviously fractured with anatomy pushed a few mm to the R, mushy to palp, significant swelling at apex and continuing up into medial/superior orbits bilat, slight drips of clear fluid from R nare, airway patent, including nasal passage, AAO x 4, PERRL at 3mm, eyes tracking properly to all fields, yadda, yadda. She refuses transport, no way to shake her. I even bring a mirror from her bedroom so she can see how screwed up her face is. I finally call her son, a priest, to help convince her. His response is, "A broken nose isn't the end of the world, she's had one before, she falls almost every week." Pt lives alone. Police called, ER physician notified. Police refuse to place her in custody, physician states that pt is able to refuse though explains to pt and son that he and I both believe that there is a significant chance of a cranial vault fracture currently and many possible current/future occult live/limb threatening pathologies possible if not likely. Son refuses.

She is home now, asleep, or dead, and I await my call back to either treat or pronounce her. Does it suck? Oh yeah, I was fucking livid! But you know what? She has the right to determine the course of her own life, either safely, or not. Tonight she believed she did right, I believe she made a terribly foolish and dangerous decision.

Dwayne,

I'm going to disagree with you on a few things. Your case with the elderly woman doesn't exactly fit here. There's a big difference between someone who is refusing care, even if it brings additional harm to them self by lack of action and actively seeking to harm them self. Actively attempting suicide, as a rule (exception being physician assisted suicide), is a sign of acute psychiatric illness which precludes the patient understanding the true consequences of their actions (I'll get back to capacity in a minute). Suffering an injury and then refusing treatment is not the same since the patient did not want the injury as a part of a disease process.

What this all comes down to is capacity to make decisions. Capacity is important because being able to answer who/where/when/why doesn't really indicate capacity. It indicates that you know where you are, who you are, when it is, and why you're there. If a disease process makes it so that a patient can't properly make decisions, then it doesn't matter. A patient who has major depression with psychotic features where the voices are telling them to commit suicide lacks capacity even if they're A/Ox4 because the disease process itself makes it so that the patient can't make decisions. I'll give a non-psychiatric example. A patient who is hypoglycemic to the point that they begin to lose mental function loses the ability to refuse medical care until the hypoglycemia is corrected. Even if they are A/Ox4. Why? Because the disease process is affecting their ability to make decisions and you don't know if they're refusing care because they don't want help for legitimate reasons or because of the disease process itself. Now, sure, amp of D50 later, "Thanks guys, I'm gonna go fix myself a sandwich, where do I sign?" is fine because the acute disease process affecting their ability to make decisions has been reversed. To take the concept of A/Ox4=everything's peachy to the extreme, then there should be no any such thing as involuntary committal.

[DwayneEMTP]

Dwayne,

I'm going to disagree with you on a few things.

And I thank you for your disagreement. Thanks for playing brother. These threads tend to die quickly when a halfway coherent contrary opinion is posted, and that's too bad.

Your case with the elderly woman doesn't exactly fit here. There's a big difference between someone who is refusing care, even if it brings additional harm to them self by lack of action and actively seeking to harm them self.

But see, this is where I believe that we split the sheets. From my personal experience I can tell you that though I've run on skads of 'attempted suicides', I'm confident that I've never truly run on one where the intent was death instead of attention. Scratches across the wrist, drinking a quart of tequila 'to end it all', taking a few of moms Viccodin, does not to me constitute and aggressive, honest attempt to take ones life. Are these cries for help? Sure, I believe that they are in many cases, simply grande standing in others. But either way I don't believe that it constitutes signs and symptoms of a person that has become acutely altered beyond the point of self advocation.

...Actively attempting suicide, as a rule (exception being physician assisted suicide), is a sign of acute psychiatric illness which precludes the patient understanding the true consequences of their actions (I'll get back to capacity in a minute).

As above.

...Suffering an injury and then refusing treatment is not the same since the patient did not want the injury as a part of a disease process.

I would argue here that the person refusing care from a trauma or acute onset pathology is much less able to advocate for themselves due to the emotional, physiological changes that take place along with such an event. If we're going to force anyone against their will, and I know that that line is very fuzzy, it should be these folks, not the coherent 'suicide' attempt. Now, I'm not exactly sure how to make my point while also making it clear that I'm not advocating, 'There's no need to transport 100 bullshit pretend suicides just to save the one person actually in danger!' My argument hinges not on the amount of work involved, but on the rights of those people that are able, to the best of our ability to detect such a thing, to advocate for themselves.

What this all comes down to is capacity to make decisions. Capacity is important because being able to answer who/where/when/why doesn't really indicate capacity.

I agree completely. But I would again state that it is my belief that the vast majority of my 'suicide' attempts were lucid, without an acute event causing the behavior. I know I'm going to take a beating on this, and I look forward to it, but with the information that I have now, that is my belief.

...If a disease process makes it so that a patient can't properly make decisions, then it doesn't matter. A patient who has major depression with psychotic features where the voices are telling them to commit suicide lacks capacity even if they're A/Ox4 because the disease process itself makes it so that the patient can't make decisions.

Again, completely agreed. And in a perfect world we would have a, hell, I don't know, one of those StarTrek thingies that would allow us to discover such things. But as it stands now, most of our protocols, and I believe the law, only allows us to force transport when that type of pathology is identifiable by us. In some cases they will be, but I don't believe that that appears to be the case in the OP.

I'll give a non-psychiatric example. A patient who is hypoglycemic to the point that they begin to lose mental function loses the ability to refuse medical care until the hypoglycemia is corrected. Even if they are A/Ox4. Why? Because the disease process is affecting their ability to make decisions and you don't know if they're refusing care because they don't want help for legitimate reasons or because of the disease process itself.

Again, certainly agreed. And in a perfect world I would again be able to treat this pt against their will. But if I see the s/s of hypoglycemia, yet the pt refuses to allow me to test and treat for it, then I am unable to develop the evidence necessary for me to treat this pt against their will. I will want to, and will exhaust every trick and trap at my disposal to do so, but if the pt is still mentating at the level that you mention, then I have no legal right to treat them. Though I know that they are physiologically altered, and I believe that that altered state is causing them to make poor decisions, unless the police decide to step in, then I have no legal right to treat this pt.

...To take the concept of A/Ox4=everything's peachy to the extreme, then there should be no any such thing as involuntary committal.

I'm going to hope that you were simply making your point and that I haven't presented my arguments so poorly that it's believed that I feel that AAOx4 is adequate information for the judging of reliable mental capacity. Unfortunately, in most cases it will be adequate for the necessary legal capacity to refuse. I've only two or three times had someone that I've truly wanted to transport refuse. One one of those I involved law enforcement and have regretted it every day since. An older woman with a hugely swollen leg secondary to cellulitis. She refused to take her antibiotics because they made her sick to her stomach. Her PCP had been consulted about this but she didn't like her options. Circulation was compromised distal to her knee and I knew that she was going to die from this infection if left untreated. She had multisystem issues, was tired, hated the hospital and truly believed that resting would cure her, and if not, then she was ready to die. I forced her to go despite, in my opinion, her being very capable of understanding her predicament, including the high risk of death, and accepted them. I involved the police, who refused to intervene, then I involved Social Services who declared her unfit to care for herself, giving me the right to force her to the hospital. To this day I believe that that is THE most morally/ethically bankrupt thing I've done as a medic. Is my decision going to be popular here? Sure. Would that be a feel good story to tell at parties? You bet. But I took away the rights of an old woman, mentating perfectly to every way that I could find to test her, except that she made a decision that I disagreed with, and forced her from her home so that she could die in a place that she hated. And we should all call bullshit on that.

But again, I pose the question. If a clinically obscure mental alteration is all that is necessary to force transport, then aren't we then obligated to force the obese, the tobacco user, the chronic alcoholic? Each of these as well has been well proved I believe to involve mental/physiological aspects that are beyond the individuals ability to control with the available tools in their current toolbox. The only difference I see between them and the attempted suicide is the timeframe. One is simply going to die sooner than the other, but all will ultimately die secondary to their pathologies, right? Do they all then lose the right to refuse?

Thanks for you post man. I look forward to your thoughts.

Dwayne

Edited May 23, 2010 by DwayneEMTP