Poss ETOH AMS Inside vs Outside

[Richard B the EMT]

On another string, a member asked about transporting a patient who may be drunk, and is definately Altered Mental Status possibly due to the ETOH ("booze"), but wants to decline transport to, or evaluation at, the ER, to the point of asking you to leave theml alone, or leave the location.

If the person is streetside, some of our policies allow for the LEOs to make the decision by placing the individual under "Protective Custody", as the individual may be a danger to either others or themselves.

However, in reference to the other string, what if the individual is in their own place of residency? What are your local policies on removing said individual from their home? Does your agency even HAVE such a policy?

If possible, please refer to your agency ops guides, county or parrish protocols, state or provence protocols, or national protocols, and not on your emotions, as I am attempting to resist such temptation, myself.

[Medic2588]

My policies have always been if they are a danger to themselves I should do everything within my power to try to convince them to go. If that fails, I can request the PD do the same. Most PDs I've worked with are extremely reluctant to force someone to go from their own house unless they are a clear threat to themselves. If that fails, I call the medical control physician and pass the buck up to him/her. If the doc can't talk sense to the patient we leave them.

[Kaisu]

If the doc can't talk sense to the patient we leave them.

That used to be what we did too... then the new protocols came out and the doc in the box WILL NOT make the decision for us. He says "I'm not there - you call it" putting the decision back on me as the medic on scene.

If I genuinely believe there may be an issue (trauma to the head, face, poor vitals, etc.) I will do everything in my power to talk them into coming in. I can usually do it too...

I have taken in 3 or 4 patients in the last half year or so against their will. Not an easy call to make but I make the decision with trepidation and based on my best judgement.

[HERBIE1]

My policies have always been I should do everything within my power to try to convince them to go. If that fails, I can request the PD do the same. Most PDs I've worked with are extremely reluctant to force someone to go from their own house unless they are a clear threat to themselves. If that fails, I call the medical control physician and pass the buck up to him/her. If the doc can't talk sense to the patient we leave them.

if they are a danger to themselves

I removed this phrase to illustrate a point. This implies the person has either temporary(ETOH related) or permanent- psych problems. That means they are incompetent and cannot refuse- regardless of where they may be.

If it's only an issue of POSSIBLE or POTENTIAL problems- "What's if's"- that is a different story.

[hatelilpeepees]

Here is how I always made the decision, I would say "if my entire interraction with this patient was video-recorded, would I be proud of how I looked when it was played in court". If I could not answer "yes" or know that I was completely covered, I transported.

[DwayneEMTP]

...If possible, please refer to your agency ops guides, county or parrish protocols, state or provence protocols, or national protocols, and not on your emotions, as I am attempting to resist such temptation, myself.

It would appear brother that such things are not necessary once you've earned a medic certificate. It seems to be the thinking that once that's been done you have now been given the authority to remove people, Nazi like, from their homes and no such things as silly laws and Civil Rights need be a concern..

Thanks for starting this thread and trying to answer this question...but the, "I might get jammed up if I leave them" or "They brought it on themselves by drinking!" or "It's the right thing to do because it feels right" crowd is either unable, or unwilling to be caught up in a debate about such things..

I once had an old woman, 2 days post hospital release, that had a foot/calf/knee raging with cellulitis. It was hugely swollen, locally red hot to the touch, generally febrile, painful to her, but she was convinced that if I took her to the hospital that they would not allow her to go home but instead put her in a nursing home. I tried everything including telling here that if she didn't come that I would almost certainly find her dead the next morning or soon after. She claimed that she would rather die at home than be a prisoner in a nursing home.

I talked to her, got one of our lady medics to talk to her, Med Con talked to her on the phone...no family or close friends...

Did I want to take her? Oh yeah...but I had no right to do so! She was an adult woman, had lived for 70+ years using her own mind and making her own decisions...it was my decision to allow her to stay home and come and check on her every several hours in the hopes that as she got sicker she would change her mind.

Another neighbor called again, a different medic showed up, called the police, who refused to take her into custody, then social services who made her legally unfit to refuse transport and they took her to the hospital. After several days of IV antibiotics she was in fact not allowed to return home and killed herself in the local nursing home.

My coworkers thought that I was the biggest moron ever..and of course they were right, in general. But I asked them the same question, "By what legal right would I have taken her?" And the answer, almost universally was, "Good God! Just take her! What's she going to do?!?" As she was old, and not wealthy with no one to advocate for her...

Now, the suicide just happens to be the real ending to this story, but it's not meant to add weight to my decision to leave her home. But she should have been allowed to live out the remainder of her life as she chose. And a drunk should not be forced out of his/her home and into an ambulance and taken to incur a ton of bills that they may never, ever recover from simply because someone says that they heard somewhere there's a law, or a protocol or some such nonsense that says I can/should do that.

And I do have to believe that all here are truly operating on hear-say as after being asked over and over, in multiple ways, by multiple people, not a single one has been able to legally justify their arrogant attitudes regarding taking people against their will. And these are some of the best providers at the City..

And those same providers have turned tail and ran as soon as this conversation got down to brass tacks...And I'm on crack?

Truly sad I think...

This kind of goes back to my career long argument that there should be at least as much time spent on the morals/ethics and legalities of EMS as there is on pharmacology...probably a lot more.

Dwayne

Edit..to add the old woman story and what follows.

Edited June 12, 2011 by DwayneEMTP

[ERDoc]

This protocol is more of a restraint protocol but it might be what you are looking for. It is from the system I used to be part of (Suffolk County, NY).

http://www.suffolkremsco.com/clientuploads/2011_Protocol_UpdateBLS_ALS/USEOFRESTRAINTPOLICY.pdf

[DwayneEMTP]

This protocol is more of a restraint protocol but it might be what you are looking for. It is from the system I used to be part of (Suffolk County, NY).

http://www.suffolkre...RAINTPOLICY.pdf

Thanks for that Doc...

Copied from that document..

There are situations in which the interests

of the general public outweigh an individual’s right to liberty, including;

the individual is threatening self-harm or suicide; and/or

the individual presents a threat to third parties, including medical care-givers

You know, it's not the need to take some people against their will that gets my panties in a bunch, but the cavalier attitude of the "If they can't refuse, I'm taking them, period." crowd. I'm not sure where this arrogance comes from, but I have to believe that the confidence in which it's stated comes from a history of violating peoples rights successfully. It also shows a terrible lack of oversight by EMS agencies as well as concern of, or at least reporting of, such instances by the hospitals.

I actually believed that the medical 'load and go' mentality wasn't thriving in the providers here. But the message seems to be, "I'm here, I'm not going to fuck around all night trying to figure out what's right or fair, so your dumb ass is coming with me."

Doesn't the complete lack of any need..in fact, any desire to justify their legal standing in this issue make you just a little bit batshit crazy?

Every core of my paramedic soul believes that patient advocacy is the blood that flows through EMS (and others of course) veins and allows forgiveness for out mistakes. The whole, "I DO advocate for my patients! Well, not drunks and drug addicts and such, but REAL patients! Well, you know, unless I might get in trouble, but otherwise I DO advocate for them!" ideal truly breaks my heart.

Surly you're seeing these patients Doc? The ones that are 'pretty drunk' or unwell, claiming that they didn't want to go to the hospital? Is anything done about that?

Dwayne

[Lone Star]

First off, I didn't realize I was going to start such a shit storm by asking that question!

Here's my take on the whole deal:

We know that there's certain criteria established to be able to make an informed decision to refuse medical attention. One of the first items of that list is that they be COMPETENT enough to be able to make that decision in the first place. ETOH, drugs, and certain medical conditions and trauma will negate that condition (diabetic emergency, stroke, head trauma to name a few).

With these conditions present, we are free to treat them based on the concept of 'implied consent'. This means that we have to establish that they're in a predicament/situation that if an average unimpaired person of normal intelligence would ask for help and want to be treated.

We know that drugs, ETOH and other chemicals taken into the body (either by inhalation, ingestion, injection or transdermally) WILL alter mental status/capactiy.

What is the difference between the patient who is 'drunk off their ass' and the patient who is 'gorked out of their minds' by some other chemical? Why is it acceptable to take one in and not the other? I'm intentionally excluding the trauma and medical patients simply because of possible underlying life threatening conditions.

How is it that the person at home who has a BAC of 0.18 should be treated differently than the 'urban outdoorsman' who has a similar BAC? Is it because the patient found at home HAS a 'home', and the other patient does not? If both are 'falling down drunk', do they both not present a clear danger to themselves and possibly others?

Sure, the 'urban outdoorsman' could stumble into traffic, get hit by a car and be killed; but by the same token, the patient at home could stumble in to the bathroom to puke their guts up, slip on that cute little bathmat...fall, striking their head on the tile wall and die in a heap in the bathtub...

We don't have the equipment to determine the level of intoxication; we can't definatively state that one is legally drunk, while the other is one of the 'walking embalmed'.

If both people mentioned above are refusing treatment/transport, would you leave the both of them where you found them and simply state "they don't want to be seen; so no harm no foul"?

We can throw in a list of 'what ifs' from now until next Christmas, but the point still remains that both individuals have an altered mental status, and by definition cannot make a clear and informed decision to refuse treatment based upon their similar condition. We also know that based, on the intoxicant involved; they are at least at risk of further injury.

[uglyEMT]

Ok time for my take. I am in an area where this comes up ALOT both ETOH and other illicet drugs / chemicals.

Here is my take on it. We have no standing protocols other then what is normally applied to consent laws thus it leaves us as providers to make the call.

When I know ETOH is onboard, I do a set of vitals. If those are within "normal" limits OK check no immediate health risk. Then I check to see how "awake" they are. Are they likely to be passing out in the next few minutes in a pool of vomit and suffocate? OK if that doesn't seem like a possibility then I move on. I survey the scene, how many empties are floating around? What is the size and gender of my patient? What is the past history? Do we have friends and family? Do they make strange (suicidal) comments? Plus probably a hundred other minor thoughts in my head as I survey my patient.

Then I think what does the consent law say. Implied consent means anyone that is not in a capacity to think for themselves do to AMS that would otherwise want medical attention. OK so now that is established what MEDICAL need does this patient have? Well beyond the ETOH and possible liver disease there is really no medical condition I am witnessing. Are they a danger to themselves or others? In your own home, sitting on the couch, watching TV, in an inebriated state but is not suicidial or showing signs of ETOH poisioning... NO MEDICAL NEED. Thus RMA, here sir / miss please sign here, have it witnessed, on my way. This goes for urban cowboys as well, just because a street corner or allyway isn't your home it isn't my place to say its not their home. This is of course dependant on weather conditions. If its going to be very cold, take them hypothermia is a medical condition that will only be exaserbated by the ETOH. Heat wave, again take them, hyperthermia again medical condition. Anything else leave them be.

NOW.. illicet pharmacology.....

This is a whole different ball of wax. I get there and someone called because so and so is acting strange. After some history taking I come to find out it is an illicet chemical. OK I check my little book to find out what exactly are the S&S and possible side effects. Ok with that information I go and check vitals. Now if the vitals are out of wack its now an immediate medical condition that needs treatment thus implied consent kicks in. Illicet pharmacology is a hard call sometimes but it depends on my survey and feelings. Usually it is a transport only because the vitals go haywire but sometimes they are not and so and so is not in immediate danger so RMA BUT I stipulate to the people who made the original call that if anything changes call us back immediatly. Ihave no problem going back but if I do come back they will definatly go for a ride.

Again alot of my decision making process is from life experience and I really can't quantify it into words in a post. Its my decision and if I feel you need transport I will try my best to get you to go but if you as an adult do not want to go unless I have a legitimate medical reason to take you then nope you get to stay put, sign my RMA, and I will be on my way. Do others on my squad feel this way, no, most feel ETOH or illicet means AMS thus implied consent, then these folks get a ride to the hospital, sit in a bed ina hallway and sleep it off, get a huge bill for bed rest and think to themselves next time I wont call or if my friend tries to call I will just leave. Thus we now have a future patient that will be combative and unreasonable.