Got really drunk and Paramedics were called

[tniuqs]

Your best bet when you have legal questions is to consult a lawyer. As for what the paramedics did, you should contact them.

Agreed or consult an advice column.

[fiznat]

This is different in my book. If you come into my residence and take me to the hospital against my will simply because someone called and you found me drunk, I'm going to sue your ass off. I have every right to forget the name of my hotel and the city that I'm in. There is no law against that and it is not an absolute sign of a life threatening pathology.

It isn't different in my book. The presenting problem wasn't "drunkenness," it was altered mental status. Patients with altered mental status are incapable of making an informed decision regarding their AMA refusal, and therefore cannot refuse. As far as identifying true altered mental status, well, we all know that can sometimes be tricky. Asking a patient basic information about who they are, where they are, what's going on, etc are generally part of the basic standard for assessing whether a patient is alert and oriented (by definition). If one of my patients fails that test, I won't let them refuse.

Also for the record, a recent history of alcohol consumption does not necessarily indicate altered mental status. Not for my patients, at least. Altered mental status is a clinical condition that I assess independently of whatever happened before I got to the patient's side.

AMA is Against Medical Advice. I'm not sure why they had him sign anything if they found that it was a false alarm, as it would not have been my advice for him to go to the hospital if he didn't call, though I'm not sure how this works most places.

It doesn't matter who called, and it wasn't a false alarm. True we don't know what the OP looked like that night and how well he was able to respond to questions etc, but it sounds like he was altered. Thats a legitimate EMS call that needs to be documented properly.

At the last place I worked at I would simply have called in, "Pt didn't call for an ambulance, no medical needed here." I'm not sure what a refusal would do when you know that you're getting a signature from someone unable to legally give it at this time?

Recipe for disaster. If the patient is "unable to legally give a refusal" on the basis of his altered mental status, that patient needs to go to the ED. Any other result is asking for trouble for all involved. This is basic EMS!

On what grounds would you have forced him to go to the hospital?

On the basis of implied consent. This patient has a presenting medical problem and is not alert and oriented. That's exactly what implied consent is for.

If your neighbor gets pissed because of your loud music and calls an ambulance saying he saw you stabbed, just to break up your party, are you then going to allow them to take you to the hospital, and incur those bills, simply because you're too drunk to sign a refusal?

Yes. If you get so drunk that you are incapable of answering questions appropriately and in the opinion of EMS are not able to understand the potential risks of a refusal, then it is on you for getting that drunk. Off to the hospital you go.

If you see a life/limb threatening event, then you certainly need to take different steps. But not in this case.

Altered mental status is a serious medical condition that has lots of causes-- many of them very serious.

FOR THE OP: Just so there isn't any confusion, we're not suggesting anything wrong was done in your case. We don't know the details of what happened and what the EMS crew saw when they assessed you. If they let you sign a refusal, chances are you satisfied them that you were capable of refusing. We're just discussing general principles here as these can sometimes be tricky situations.

Edited June 8, 2011 by fiznat

[DwayneEMTP]

...

It isn't different in my book. The presenting problem wasn't "drunkenness," it was altered mental status.

No, according to the OP the issue is drunkenness you just decided to stop assessing at "Altered mentation of unknown etiology." You were actually called for a cardiac arrest, almost certainly by another drunk. There was no cardiac arrest, or anything that would lead anyone to think that there might have been, therefore you have no further business in this mans house if he's asking you to leave.

... Patients with altered mental status are incapable of making an informed decision regarding their AMA refusal, and therefore cannot refuse.

This person did not call for an ambulance (I'm assuming he didn't call in his own arrest) therefor you had no right to be there. At the point that you discovered that he didn't call for an ambulance, and did not in fact want one, you became a guest with no legal standing whatsoever in his home. If you had found him with one arm hanging on by a thread of flesh you would have no legal right to force him to the hospital if he was able to mouth the words necessary to refuse. You may be able to convince some disgruntled cop to threaten him into your ambulance, but you have no legal right to take him.

According to your theory you should be able to walk down any street asking random strangers questions and have the legal right to force them into your ambulance and take them to the hospital against their will should they be unable to answer them. Negatory good buddy. Ask my son who the president is, when his birthday is, how he's feeling, and he most likely won't answer you, (He knows, he just won't tell YOU) and yet you still, that's right! even you with your Godlike paramedic powers to decide who is worthy to stay home and who isn't, have no right to put your hands on him. And if you do I'll make you sorry.

...Also for the record, a recent history of alcohol consumption does not necessarily indicate altered mental status. Not for my patients, at least. Altered mental status is a clinical condition that I assess independently of whatever happened before I got to the patient's side.

You assess your patients independent of their history, even when they're able to speak? That's weird. If they say they are drunk,that is important information in my assessment...in fact I'll do everything in my power to prove that alcohol is not covering up an underlying issue, but a thorough history belongs in a decent assessment. If you refuse to consider alcohol as a cause of altered mentation then I can see why you're kidnapping so many folks. Altered, admits to drinking, friends and family admit that they've been getting snockered, claim he always acts like this when he's drunk, stroke scale is neg, vitals acceptable for situation (If allowed to take them) BGL unremarkable? He's staying home if that's his choice...anything else is just simply arrogant moral policing. Assuming an non fragile population of course.

I've never arrived on a call for a drunk expecting to see a drunk. It's always a finding of exclusions. But are you telling me that you have forced every elderly person, every drunk, every mentally challenged person with a skinned knee into your ambulance and to the hospital based on your assumption that it's your RIGHT to protect them from themselves? It's that arrogant attitude that the laws are meant to protect us from.

...It doesn't matter who called, and it wasn't a false alarm. True we don't know what the OP looked like that night and how well he was able to respond to questions etc, but it sounds like he was altered. Thats a legitimate EMS call that needs to be documented properly.

Fair enough on the documentation. But you have earned, and were rewarded with the right to be a paramedic. Nowhere on that cert does it claim that you were also made King.

...Recipe for disaster. If the patient is "unable to legally give a refusal" on the basis of his altered mental status, that patient needs to go to the ED. Any other result is asking for trouble for all involved. This is basic EMS!

No man, that's what the protocol may say, but basic EMS says that injured and ill people that request an ambulance, or have one, in good faith, requested for them and are then unable to communicate would want us to act in their best interest. You are not acting in this patients best interest, you're covering your ass for your QA/QI. You have taken the care of people to a new level of moral and ethical policing.

...On the basis of implied consent. This patient has a presenting medical problem and is not alert and oriented. That's exactly what implied consent is for.

That is so completely wrong. Implied consent is meant to protect people that can't protect themselves. This man was doing fine it sounds like, just drunk. (at least that's the information we have) What did this person claim was their medical problem that you are protecting them from? Obviously they are not in arrest! Right? So the original call is bullshit! We have entered this persons home without their consent, and are now going to take them against their will for doing something that is in no way illegal? That is truly pathologic Fiz...

...Yes. If you get so drunk that you are incapable of answering questions appropriately and in the opinion of EMS (Bolded for added bullshit emphasis) are not able to understand the potential risks of a refusal, then it is on you for getting that drunk. Off to the hospital you go.

Just try it. I'm truly shocked by this attitude. Particularly from you. This is cover your ass medicine at it's very worst when the very soul of our profession states that we must be patient advocates. You are not advocating for this drunk guy, you are flexing your muscles and trying to come up with some morally cool shit to talk about at church on Sunday. This is not good medicine as it's practiced in our country. I have a right to get drunk. I have a right to overdose on pills. I have a right to purposely injure myself....as long as all are done of my own free will, in my own home, without causing any type of harm to others and I'm willing to claim that none were done in an attempt to end my life.

...Altered mental status is a serious medical condition that has lots of causes-- many of them very serious.[/qupte]

And I was aware that I may be subject to ignore many significant things when I decided to get shitfaced. But I still have a right to be shitfaced without you causing me a gazillion dollars in hospital bills so that you can blindly follow a protocol.

The rules governing right of refusal are meant for people that are sick or injured and unable to advocate for themselves. Man, it feels really funny to seem to have to say that over and over. Please tell me you're not jumping on ol' what's his names wagon with the, "Everyone must go to the hospital because you can't diagnose dizziness without an MRI."

You're one of the smartest people on this board, there is no doubt in my mind about that, so I truly expect that there must be some way that you can school me on this...but I'm interested still to see you try.

Dwayne

Edited for a few minor grammar changes. I know....the whole thing is an abortion as far as writing goes..but I like the argument and am too tired to fix it now, so I'll take my lumps...

Edited June 10, 2011 by DwayneEMTP

[Kaisu]

No, according to the OP the issue is drunkenness you just decided to stop assessing at "Altered mentation of unknown etiology." You were actually called for a cardiac arrest, almost certainly by another drunk. There was no cardiac arrest, or anything that would lead anyone to think that there might have been, therefore you have no further business in this mans house if he's asking you to leave.

Have you been smoking crack? You really meant to state that if a dispatch complaint differs from an actual complaint you leave?

Your argument is based on the faulty assumption that someone that is drunk is in a position to make good decisions for themselves.

There is a famous case in tort law where a drunk falls into a construction hole and sues the city. The city argues that the guy was drunk. The judgement states quite succinctly that a drunk has just as much right to a safe street as a sober person, and is in twice as much of a need for one.

Figures from the Center for Disease Control for 2007 quote alcohol related deaths as follows:

Liver and liver related 14000+, non-traumatic (aspiration, etc) 23,000+.

These numbers do not include accidents, crashes.....

Just because you like to get shit faced does not mean that it is not risky behavior.

You do have the right to be in the home. Someone was worried enough about this person to call 911. They want your help. As a paramedic, I have the education, training and experience to be a better judge of what is safe for this person that is intoxicated and unable to form a good judgement. It's not cover my ass.. its looking out for my patient.

I would rather stand in front of a judge to defend myself for taking in the patient against their will when it was my sincere and honest belief that the patient was at risk than to explain why I left them and they drove their car into a bus stop full of children.

[Richard B the EMT]

If the 9-1-1 system is activated for a Cardiac Arrest, here in New York City, there's going to be paperwork, as you'll have an FDNY Engine company, both ALS and BLS EMS response, and the local NYPD sector car team. All have paperwork to fill out, even if whatever the EMD was told is nowhere near as bad as the caller described.

However, for someone who appears to be drunk, has the apparent smell of alcohol on the breath, is not aware of where/when/who they are, were it my scene, I'd be requesting the supervisor and NYPD put in an appearance, especially if the patient doesn't want to go to the hospital. Consider the "apparent" intoxication to be a distraction of some possibly worse problem. Consider something possibly diabetic in nature, at a minimum.

I make note at this point, that, due to me being an EMT, even if I am drunk from drinking alongside the "patient", I cannot call that individual "drunk", as it could be considered slander/libel, in our overlitigatious society.

[hatelilpeepees]

OK guys, take the blinders off, you all missed an important point in what she said; either she is not telling the whole truth or something much worse occured here. She admits to drinking "1 shot" of strong liquor and then was unconscious/unresponsive. There is no liquor on earth that can do that to an adult, even a shot of rubbing alcohol won't do that. My guess, you got drugged and raped by your neighbor, chose better drinking partners, or your definition of a "shot" is much different than mine.

[DwayneEMTP]

Edit: And having said all of this shit, I got this thread confused with another thread. (thanks for the heads up HLPP) I thought we were arguing the refusal on a drunk that someone called in as an arrest and, whoever, was upset because they couldn't get them to go to the hospital. Oooops.

...

No, according to the OP the issue is drunkenness you just decided to stop assessing at "Altered mentation of unknown etiology." You were actually called for a cardiac arrest, almost certainly by another drunk. There was no cardiac arrest, or anything that would lead anyone to think that there might have been, therefore you have no further business in this mans house if he's asking you to leave.

Have you been smoking crack? You really meant to state that if a dispatch complaint differs from an actual complaint you leave?

My personal crack habits aside, of course not.

I have rarely been dispatched to a call that turned out to be what dispatch claimed. I would show up, find that this person didn't call for help, nor does he want it, do an assessment to the point that I can be comfortable that alcohol is the only significant issue, yet not so significant that I believe it will cause his immediate demise, and leave the man to his life. That is how it works in the United States. I have no right to forcefully remove a person from their homes because they are drinking and I believe that drinking is going to fuck up the legalities of my refusal paperwork.

I was taught in paramedic school, and in countless environments since, to do a good, thorough assessment. Can I rule out an underlying pathology that may be killing this guy? Of course not. But I can get to a reasonable degree of certainty. But he has not relinquished his civil rights by becoming intoxicated, it's as simple as that. I give a rats ass what you're protocol requires of you, I am to be his advocate. If my assessment leads me to believe that he is simply intoxicated, as he states, then I am morally and ethically obligated to advocate on his behalf, which means following his wishes. if I reasonably believe that those wishes won't make him soon dead.

...You do have the right to be in the home. Someone was worried enough about this person to call 911. They want your help.

No, you HAD a right to ENTER the home when you believed there to be an emergency, but having found that not to be true, you are now a guest. You don't simply get to wander the house making sure that this person is not doing anything bad. They did not want your help! Someone that called for an ambulance, assumed not to be this person, wanted your help. You don't get to decide which civil/constitutional rights I am now allowed based on the fact that someone else called you and a medic patch on your shoulder.

...As a paramedic, I have the education, training and experience to be a better judge of what is safe for this person that is intoxicated and unable to form a good judgement. It's not cover my ass.. its looking out for my patient.

Bullshit. He's not your patient because he didn't call for, nor does he want you help. You can do the right thing and try to do a good assessment to make sure that nothing acutely obvious is happening, but you have not right to stay here.

The simple argument is, "We need to take him to the hospital because the alcohol may be mimicking or masking an underlying pathology that he's unable to consider on his own at this time." Then you need to take every smoker, obese person, mentally challenge person, etc, etc...that you see if you are to fulfill this mission, as they are showing you BLATANT s/s of terminally pathologic behavior that they are unable to mitigate on their own and you are then required to protect them from themselves as they have made it much more clear than this drunk person that they can not advocate for themselves. Right?

The idea that "you have fallen within my field of view and I deem you to be unsafe, unhealthy, intoxicated so I am now going to take control of your life" may make your nipples hard, but it's not good patient advocacy. A drunk has a right to be drunk in his own home, a terminal patient has a right to choose to refuse treatment and die, a child has a right to have unprotected sex risking life threatening illness/pregnancy, a person has the right to be several hundred pounds overweight risking all sorts of ugly shit. Do any of us like it? Not at all. Do we all wish that we could help them all? I hope so...but it appears that there are some of you that have come to believe that as you're now paramedics you simply don't have to take it any more. And it sounds like the systems you're in are supporting your desire to play mom/dad/God and Big Brother all in one. And that's a shame.

I have left many, many drunks home when someone else called for me. Their pissed off mom, or girl friend or husband. I was sad to see their lives, and sad that they were unhealthy, but they have the RIGHT to be unhealthy. They have the right to pilot their own boat to the harbor of their destiny. I can do what I can to help, but to pull an already damaged person out of their home and gift them with several thousands of dollars in hospital bills just seems cruel, and in NO POSSIBLE WAY can it be considered patient advocacy. And if you're so certain that you can't assess an individual that claims to be intoxicated to within a reasonable doubt of believing them or not, then perhaps your assessment skills aren't as sharp as you thought.

I don't care how good you think you are as a medic, you're not so smart that you should be given the power to molest non emergent people for their own good.

Good conversation.... :-)

Dwayne

Edited June 11, 2011 by DwayneEMTP

[NYCEMS9115]

If the 9-1-1 system is activated for a Cardiac Arrest, here in New York City, there's going to be paperwork, as you'll have an FDNY Engine company, both ALS and BLS EMS response, and the local NYPD sector car team. All have paperwork to fill out, even if whatever the EMD was told is nowhere near as bad as the caller described.

However, for someone who appears to be drunk, has the apparent smell of alcohol on the breath, is not aware of where/when/who they are, were it my scene, I'd be requesting the supervisor and NYPD put in an appearance, especially if the patient doesn't want to go to the hospital. Consider the "apparent" intoxication to be a distraction of some possibly worse problem. Consider something possibly diabetic in nature, at a minimum.

I make note at this point, that, due to me being an EMT, even if I am drunk from drinking alongside the "patient", I cannot call that individual "drunk", as it could be considered slander/libel, in our overlitigatious society.

Nowadays in NYC/FDNY EMS Cardiac Arrest will have a Conditions (EMS Lt.) Or DC (Duty Capt. If Lt. not 10-8) respond. Its been like this for 4 years now... So, it's more reasons to dot your Is and cross your Ts....

OK guys, take the blinders off, you all missed an important point in what she said; either she is not telling the whole truth or something much worse occured here. She admits to drinking "1 shot" of strong liquor and then was unconscious/unresponsive. There is no liquor on earth that can do that to an adult, even a shot of rubbing alcohol won't do that. My guess, you got drugged and raped by your neighbor, chose better drinking partners, or your definition of a "shot" is much different than mine.

With no disrespect to the Original Poster; intoxicated people or under the influence people usually fib on the amount of alcohol they consumed...

[fiznat]

This is cover your ass medicine at it's very worst when the very soul of our profession states that we must be patient advocates. You are not advocating for this drunk guy, you are flexing your muscles and trying to come up with some morally cool shit to talk about at church on Sunday. This is not good medicine as it's practiced in our country. I have a right to get drunk...

lol I swear you and I have this argument once a year. I don't really have all day to go through your points one by one so I just pulled this one out cause I think it is the main theme of your post.

I fully respect your passionate argument for individual freedoms, but I really don't think this is the place for it. One of the first lessons we should all learn as baby EMTs is that ALL medicine is "cover your ass medicine." From the lowest rank all the way up to physician. Get used to it. CYA medicine is good for providers, and it is good for patients: think of it as institutionalized diligence. I can't tell you how many times I've done something because it was routine and it turned out to reveal something major that I might otherwise have missed. Covering your ass is covering your patient's ass, too. Make no mistake about it.

If a patient is altered beyond the ability to understand the risks of an AMA refusal, the responsibility to make the right choice for that patient lands on YOU. You might as well sign the paperwork yourself. This isn't about "letting a person do what they want," it's about analyzing a situation where you - and only you - are making a potentially life or death decision for someone else. You need to respect that responsibility. It is not a rare occurrence that seemingly drunk people are actually experiencing a life threatening event. It is not a rare occurrence that alcohol intoxication alone leads to death and disability. If you decide to let an altered patient sign a refusal, know this: YOU (not the patient) are making the decision that is okay to take that risk. I don't deny that individuals have the right to make that decision for themselves, but this is a situation where you are choosing to take that risk against someone else's life. That's a big deal, and the standards need to be different.

...And before you tell me that this is not a life threatening condition, that he's "just drunk," take a moment and step back. It hurts to admit it, but YOU DON'T KNOW WHAT IS WRONG WITH THIS PATIENT. Admit it. You can't possibly. You may have a good idea, you may be 99.999% sure, but you don't know for sure. We're good at what we do, we know how to assess, we've seen it all before, I know, but have some humility. The stakes are too high to mess this up.

As far as assessing the patient, I'm going to mostly leave that alone. The whole assessment process and the decisions that lead up to deciding whether a patient is "altered" or not is -- I think we can agree -- a complex and situation-specific task that we all have to make for our own patients. If this patient is deemed "alert and oriented" (IE not altered), then there is nothing to discuss: let him refuse. The argument (and this thread) comes from the point where we have decided this patient IS altered, and he still wants to refuse....

[DwayneEMTP]

lol I swear you and I have this argument once a year...

Yeah, I think you're right. I love this argument!

I think where you and I disagree, and this may be due to our difference in age maybe, is on personal liberties. This person did not call for you (Again, assuming the drunk that wants to refuse not the OP and the rufees) nor is there reason to believe that the call was made by someone that had this persons best interest at heart, as a seemingly caring, intelligent person would have a hard time confusing an arrest with slurred speech and altered mentation. Therefore you had no right to assess this person, and you no longer have any right to be in their home.

Having come into contact with this person gives you a moral, hopefully, responsibility to try and make sure that they are reasonably safe to the best of your ability but does not give you the power to remove them from their home against their will. It just doesn't!

From those of you saying, as you have Fiz, that "they are going...done deal" by what legal authority are you going to do so? You can't use implied consent on a person that didn't call you and doesn't want to go. They have no obligation to be able to consent or not, they are in their home.

It's confusing to me that more people aren't offended by the contention that some of you seem to believe that having a medic cert also gives you the right to violate a persons right to be free and safe in their own homes.

Does it not give you pause at all that this person did not request help, that they don't want it, that the person that did request it was obviously drunk or damaged as it was called in as an arrest, so basically you are in this persons home in the first place against their wishes? It doesn't make you stop and think for one second that perhaps you've become part of the problem instead of part of the solution?

And if you take this person against their will, how do you justify not stopping and assessing every drunk you see. If you witness a fender bender, do you then force all occupants into your ambulance because they are not smart enough, or educated enough, or have the necessary experience to know that in a small percentage of such accidents that a pathology caused the accident or that in a minute population there will be hidden injuries? I mean, surely you must. Your argument is that because you're smarter and more educated that you have the right to force people into what's best for them, or is this only a drunk thing for you all? I mean ignorance of consequences is ignorance of consequence whether self induced, brought on by pathology or simply inherited by upbringing, right?

Why protect some and not others? What is the litmus test for those that you will force to be proved to be pathologically free and those that you won't?

Dwayne