Instruction in what to do.

[P_Instructor]

How many of you instructors deal in instruction in what is really best for the patient in odd situations. Example:

I was working a shift with a newer inexperienced paramedic the other day. His rotation as the attendant. Dispatched out for possible injured party. Arrived scene and FD EMS meets us outside residence stating just to bring clipboard as patient is refusing transport. We still took the cot and jump kit, etc near the door and entered the home. Found near 100 year old female supine on bedroom floor with lower legs under bed frame. She was only dressed in nightgown, typically weighed only 90 lbs. She was conscious and alert without complaint other than having to go to the bathroom. Apparantly, has been up and down this morning, very unsteady on feet, needs assistance by way of grasping furniture to be mobile. She was found by friend/hairdresser because neighbor called friend to check on patient after not noticing any lights on in the home from across the street which is atypical. Friend activated 911 response.

Assessment was unremarkable for the patient except for slight pressure bruising to elbow and shoulder point from lying on hard floor. Skin was cool and dry. Partner could not obtain auscultated BP, but patient has good carotid pulses and regular apical heart beat/tones in 60's. The patient only wanted help off the floor to go to bathroom.

I jumped in and took over as partner seemed a little perplexed and after letting patient know that we would remove her from the supine situation, that if there were any changes (which we thought there would be) that we would take her to hospital for evaluation. Ahhh, this is the point that the ole gal stated 'no you will not' in loud/firm/demanding tone.

Long story short, got her up without changes and assisted her to commode, then to sofa in living room where she wanted to go.

The problem at hand is that the patient could not ambulate sufficiently enough in my opinion to be by herself, however, she stated otherwise.

Have you, or do you ever instruct students on what you could do in these type of situations?

It is the inevitable identify/adapt/overcome type of scenario.

Give some opinions or ideas. I will let you know what I ended up doing in leter posts.

[rat115]

This is where I'd ask the student if I could make a suggestion since he/she's training. I would suggest to ASK the pt to show that she can ambulate significantly to move around when left alone. If she is unable/unwilling to do so, I ask why and depending on the answer may tell her that it's my suggestion that she be evaluated at the ER.

As long as the pt is AAOx4 and there is nothing telling us that self-neglect or possible self-harm is going on, there is nothing that can be done to force the pt to go. Often with the elderly, they will become upset (as you noted) when told "that if there were any changes (which we thought there would be) that we would take her to hospital for evaluation." I've found that when you talk to them, they've had so many of their freedoms taken away by their age and disabilities that they get defensive when they feel that EMS or medical providers are taking away their right of choice. We have to remember not to make a pt feel forced to get evaluated unless there is a reason such as altered mental status, ETOH/drugs, or threats of self-harm. In these situations, we need the area LEO to back us up and to make the pt feel that this is us caring for them and not forcing them.

I had a pt who had attempted suicide by taking too many painkillers, but it wasn't enough to actually kill him due to his tolerance. He became irate to the point of telling our ALS provider on the call to get out of his home and not to come near him again because the ALS provider said similar to what you did and started giving orders. One of our volunteer Basics who's a minister was able to convince the man to let us take him in, get him checked out, and get him counseling simply by treating him with kindness and showing concern for his well being. It was a lesson in non-pressure for me.

[P_Instructor]

OK, not many replies. Situations like this are more frequent than most realize. As instructors, open the suggestions and lead them to do what is best for the patient, or be that patient advocate, whether they want the help or not.

I ended up speaking directly with the son in another state, the State DHS, and got those entities hooked up. Also asked if the friend could stay and watch over the patient (which she was very glad to do and even would stay through the evening and night, with approval from the patient and son). All this is made aware to the patient.

EMSer's must realize that we are not there only for the physical patient care, but for the needs of the patient/family, whatever it may be. This goes along with the moral/ethical aspects which should be stressed even more in the classroom instruction.

Comfort and compassion and the wanting to do what is right goes a long way. I have been in the business over 30 years, and this was the first time that I was thanked by all parties involved. Even received hugs from the patient and friend.

[scubanurse]

I was never specifically trained to handle these situations but it is a good one to bring up during training.

I have run many situations like that as the population in my first due was mostly elderly. I would appeal to their sense of grandmother/father-hood. I would tell them since I am a young provider that if they were my grandmother/father I would want them to get evaluated because what if it happens again and you get hurt more seriously. It generally would work with me and when it didn't, I would go back to the station and call the social workers I knew to go do a home eval with the family to make sure it was still the best place for the patient and assist the family in getting at home nursing care or home placement.

good topic

[crotchitymedic1986]

The answer for all "weird" situations is the same, get medical control involved.

[P_Instructor]

The answer for all "weird" situations is the same, get medical control involved.

The problem is when you cannot get ahold of MC, then what are you to do. You need to be able to use your resourcefullness to do the right thing. By the way, MC couldn't give me much info in this situation.

[FireMedic65]

I always made it a point to allow the students to handle the situation until I felt I needed to step in. I also always taught them to expect the unexpected. You will always have to adapt to different situations where as a scenario in the book is too text book to base off of in the field. You are also the patient advocate. Even if they tell you they are alright, it is still your responsibility to ensure they really are.

If the patient refused to go, then that's that. But your job still isn't done. You should make sure the patient will be okay after you leave. Ask a neighbor to check in on them or a family member if they are close.

Sometimes just talking to the patient like a person and not a patient can go a long way too.

[brentoli]

It is important to remember that people control their own destiny. This is something I try to keep in mind whenever I am faced with a situation I cannot understand.

Some people have such a strong desire for independance that they are to the point of self destruction. It sounds like this lady may be headed on that path. Sadly as long as she is aware of what she is doing, we can't put up a roadblock. You took the right steps in speaking to the family and also the proper authorities, even if they cannot address the problem directly they will have the file for her.

I have contacted MC a few times in situations like these, and their hands are tied just as tightly as ours.

You just have to get the student to belive in thinking outside the box. Its a difficult skill to learn, I have been in EMS 6 years now and I still struggle sometimes. What I would do is take the incident and throw "what ifs" into it as you discuss it and develop the critical thinking skills where they can relate it to the real world. Those sorts of learning moments have always impacted me more than just the RRR's.

[crotchitymedic1986]

If you are unable to get MC involved, then you should rely on your supervisor.

[DwayneEMTP]

I don't see a need for either medical control or my supervisor in this situation, as it truly is relatively straight forward if you've been taught critical thinking skills.

I think that this thread is an awesome idea. As I've said many times in the past, I believe the vast majority of my most difficult decisions have been moral/ethical, not medical. And I don't think that I see a lot of this being taught, and very seldom see it practiced. I think we need a forum just for moral/ethical scenarios.

When I state that the above scenario is relatively straight forward what I mean is that if I begin at the beginning, the fact that I am there not to cover my ass, but to be a patient advocate, then forcing this woman out of her house if she's mentating properly is going to be so far down on my list of possible options that it's unlikely that I will ever get there. She has a support system in place and is healthy enough to choose to rely on it instead of going to the hospital. Educate her and the neighbor to watch the bruises as they can become a significant health risk in a pt of this age, help her to the bathroom, get her comfy, make sure her telephone is within reach, remind her that I would like nothing more than to come over and help again if she needs it, and then document the shit out the call in case something goes sideways.

Easy, right? I'm not sure at what point MC or a supervisor would have become useful unless I believed her to be significantly damaged and I couldn't change her mind about transport.

Great thread. It would be fun if everyone posted their 'weird' calls, right? So we can flex our brains a little bit down this logic path.

Dwayne