Ok, this should be a fun one.

[HERBIE1]

We've been through this before. These people absolutely CAN refuse transport. It doesn't matter what was wrong with them before or what they will be like in 30 minutes. If they are competent to make their own decisions at the time they refuse you CANNOT take them. It is your job to try to convince them otherwise, but ultimately if you assess them and they understand the risks and benefits and they have the capacity, there is nothing you can do to make them go. To force them to go is basically kidnapping. Having the capacity to make such a decision also means more than being A&OX3 or 4. They have to understand what is wrong, why you want them to go and what the consequences of not going are. Denny, your instructor may want to review the law before he gets himself or one of his students in trouble.

As for contacting medical control, that all depends on your protocols/jurisdiction.

Let me preface this by saying I work in a VERY conservative system- think 25 years behind the rest of the world.

I have had several attending and EMSMD's tell me they would never allow someone like this to refuse prehospitally- for the reasons I mentioned. I get what you are saying about the kidnapping part, but I happen to agree with our docs on this. I would HATE to have to defend myself on a case like this in court. I would much rather have to defend why I took someone for definitive care who SEEMED to be fully awake, then have to explain how I "knew" the patient no longer had narcotics in their system and would not have a "relapse" but still ended up dead. By receiving a response to the narcan, it's essentially proof they were under the influence, and unless we do a tox screen, how can we know if they have metabolized all the drugs that clearly were in their system when we encountered them? In the case of any refusal of transport, all we can do is go by our assessment, of any evidence they are under the influence or incompetent in any way, but when we KNOW the person was under the influence, how can we assume their competence?

The kidnapping idea has been drilled into our heads for years, yet I have never heard of a case where such a thing was charged, much less been proven.

For years we would do the routine narcan pushes on chronic OD's, they would be fine and ready to do it again, but over the years, the strength/purity of the drugs seems to have increased exponentially.

A few years ago we had a rash of OD's here where the heroin was laced with Fentanyl, and it took "gallons" of Naloxone just to get some of these folks breathing again. We saw many times where they would become fully awake and seemingly competent- only to see them nearly go apenic again. No, not every OD is so profound and intractable, but how can we be sure? Seems like a huge liability issue to me.

[EMTDenny]

I'll agree it's a shitty situation to be put in. Sued by the family or sued by the pt. Which is worse? If you let them RMA and something happens, yes, the PCR will be looked at. That is why it is so important to document everything. This also why on a NYS PCR there is a place for a witness to sign the RMA. If you can, have the family be the witness and make sure you explain everything to them so that they understand why you can't make the person go.

I agree.

A few years ago we had a rash of OD's here where the heroin was laced with Fentanyl, and it took "gallons" of Naloxone just to get some of these folks breathing again. We saw many times where they would become fully awake and seemingly competent- only to see them nearly go apenic again. No, not every OD is so profound and intractable, but how can we be sure? Seems like a huge liability issue to me.

That does look like it can be a liability problem. I have no experience what so ever with this drug Nalaxone , but maybe they should come up with some kind of protocol, when it is given to the patient they can not RMA. It seems to me that every time a patient is breathing again, once Narcan is used they can be competent and A&O to the max to RMA. Just saying. I've experience this before.

[Kiwiology]

Your instructor is an idiot and should have it written across his forehead in big red letters

A patient has the right to refuse treatment and transport including that which may be lifesaving until proven incompetent

Because you overdosed and got woken up does not mean you are not competent

Bottom line if they can consistently tell me they do not want to go, why they do not want to go, that they understand the risk and they can call back to go or go themselves if they change their mind, then I have no problem leaving them at home.

I've seen it happen before with my own two eyes in fact!

[EMTDenny]

Your instructor is an idiot and should have it written across his forehead in big red letters

A patient has the right to refuse treatment and transport including that which may be lifesaving until proven incompetent

Because you overdosed and got woken up does not mean you are not competent

Bottom line if they can consistently tell me they do not want to go, why they do not want to go, that they understand the risk and they can call back to go or go themselves if they change their mind, then I have no problem leaving them at home.

I've seen it happen before with my own two eyes in fact!

Wow this is why I love EMT city. Plenty of opinions to go around. Love it.

[ERDoc]

I would HATE to have to defend myself on a case like this in court. I would much rather have to defend why I took someone for definitive care who SEEMED to be fully awake, then have to explain how I "knew" the patient no longer had narcotics in their system and would not have a "relapse" but still ended up dead. By receiving a response to the narcan, it's essentially proof they were under the influence, and unless we do a tox screen, how can we know if they have metabolized all the drugs that clearly were in their system when we encountered them? In the case of any refusal of transport, all we can do is go by our assessment, of any evidence they are under the influence or incompetent in any way, but when we KNOW the person was under the influence, how can we assume their competence?

Would you rather defend yourself in a civil case or a criminal case? You should not be explaining how you knew the person no longer had the narcotics in their system. To do so would be perjury since we know they are still in their system. We also know they ARE going to relapse, there is a chance they will not but I always assume they will until proven otherwise. Again, that is were your proficiency as a provider and proper documentation come in to play. You need to make it clear to the pt and family what will happen. You can also explain to LEOs, "I can't force him to go but he will go down again." Some will take the pt into protective custody and then can be forced to go, but by the LEO. You cannot force them to go. You should also not have to "assume their competence." You should be doing a proper assessment and be able to document their competence. The best bet is to use all of your resources. Tell the family that he will stop breathing again in 30 minutes and that someone should be with him at all times. Explain the same thing to the LEO. You cannot force something on someone just because they might not be competent in a little while. They are competent when they make the decision and that is all that matters.

[Kiwiology]

Love you too bro

Unlike Dwayne or that Emergentologist bloke, they just say they love me, pricks!

Damn Emergentologists posting before me, I know naloxone only has a short duration so I am going to go look up this relapse thingamajingle, interestingly nobody here has mentioned it when we talked about leaving patients at home who have recieved it and refuse transport

In Australia the Metropolitan Ambulance Service (Melbourne) has been waking people up and leaving them at home for twenty years or more as they (at one point) had a huge heroin problem, anecdotally they say its quite safe

Edited February 24, 2012 by kiwimedic

[ERDoc]

Aww hell, I love Denny too. He's from the best state in the union. What's not to love?

[Kiwiology]

Great Nation of Indiana > New York

Damn New Yorkers, can't understand a bloody thing they say, and their volunteer EMTs in the upstate don't even come with a blood pressure cuff!

[Eydawn]

FYI Denny: Naloxone = generic for Narcan. Good thread start!

I would have to agree with the idea if you're not confident that this patient will be safe after you leave them, hang around for a while. If they go down again, then put them in the truck and don't wake them fully back up till you're closer to the ER... then there's implied consent, and you did the best thing you could for the patient while preventing a needless transport.

What's the duration time of Narcan, average? I don't have my Epocrates window open... is it dependent on how much opiate is in the patient's system? (That's for you paramedic/MD type folks... I guess I could go look it up, but I'm really tired tonight!)

Wendy

CO EMT-B

[EMTDenny]

Love you too bro

Unlike Dwayne or that Emergentologist bloke, they just say they love me, pricks!

Damn Emergentologists posting before me, I know naloxone only has a short duration so I am going to go look up this relapse thingamajingle, interestingly nobody here has mentioned it when we talked about leaving patients at home who have recieved it and refuse transport

Aww hell, I love Denny too. He's from the best state in the union. What's not to love?

Great Nation of Indiana > New York

Damn New Yorkers, can't understand a bloody thing they say, and their volunteer EMTs in the upstate don't even come with a blood pressure cuff!

HAHAHA, damn those upstate Volleys. When I volley we have blood pressure cuffs in the bag.

FYI Denny: Naloxone = generic for Narcan. Good thread start!

Thanks! Wendy.