P_Instructor Posted October 9, 2012 Author Posted October 9, 2012 Maybe the nurse can drive him on her way home. Ha....love it, except the nurse would probably shove him out of the car.
MikeEMT Posted October 10, 2012 Posted October 10, 2012 Ok, first of all he has doctors orders. Because they are calling for an ambulance for the transport that tells me he is already confined. Second, he jumped from a moving vehicle on purpose. That to me indicates suicidal tendencies. Third, he is a Psych patient. You would be hard pressed to find anyone that would label someone going into a psych eval as "competent." Obviously, there is a behavior that has been demonstrated to indicate to healthcare professionals that he needs further evaluation. Maybe its my legal background talking but I see this as a non issue. Now, if this was an emergency call and you responded to the scene rather than the hospital you would have to use your judgement based on the totality of the circumstances. As I mentioned in my previous post, per my company we wouldn't transport unless ordered by a mental health professional or a court. I would have no problems transporting this patient because of the doctors order and the history of self harm (jumping from a moving vehicle). Document everything.
Arctickat Posted October 10, 2012 Posted October 10, 2012 ummm...the entire reason he's going for a psych evaluation is to determine his competency and if he should be committed, Until that evaluation is complete he retains the right to refuse. Doctor's orders or not, he can not be forced to go.
island emt Posted October 10, 2012 Posted October 10, 2012 Ok, first of all he has doctors orders. Because they are calling for an ambulance for the transport that tells me he is already confined. Second, he jumped from a moving vehicle on purpose. That to me indicates suicidal tendencies. Third, he is a Psych patient. You would be hard pressed to find anyone that would label someone going into a psych eval as "competent." Obviously, there is a behavior that has been demonstrated to indicate to healthcare professionals that he needs further evaluation. Maybe its my legal background talking but I see this as a non issue. Now, if this was an emergency call and you responded to the scene rather than the hospital you would have to use your judgement based on the totality of the circumstances. As I mentioned in my previous post, per my company we wouldn't transport unless ordered by a mental health professional or a court. I would have no problems transporting this patient because of the doctors order and the history of self harm (jumping from a moving vehicle). Document everything. I guess that you have a degree in psychology or psychiatry that qualifies you to make those determinations??? Just because he is alleged to have jumped out of a vehicle by someone else means little in the present time. It is alleged to have happened two days earlier. In legal terms I believe that would be called hearsay . You need to make an evaluation of the Pt's current condition and evaluate based on what YOU see , hear and intuit from your questioning of the PT. He is not under protective custody or court order for eval, To force him against his wishes would be a big mistake on your part. If the Facility DR wants him evaluated then arrange for it to happen without placing the EMS crew in the middle of a legal conundrum that could potentially bite them in the arse. If you transport under a mental health professionals orders against a competent Pt's wishes then you are placing your service at risk. Without a bluepaper order from the court or protective custody from law enforcement we cannot force them to go. Yes I have transported folks that are making threats to harm themselves or others by using the law enforcement option of the law. They are taking the Pt into their protective custody, and offering them the opportunity to ride in comfort with us or handcuffed in the back of the cruiser. Sometimes they are handcuffed on the stretcher if the threat is serious enough, and the officer rides in with us.
Bieber Posted October 10, 2012 Posted October 10, 2012 Ok, first of all he has doctors orders. Because they are calling for an ambulance for the transport that tells me he is already confined. Not trying to talk down to you or anything, man, but I gotta say, that kind of mentality seems dangerous as hell to me. Maybe it's just me, but I don't trust anybody to have done anything unless I was physically there and saw them do it or can confirm it for myself (except for my partner and the other folks who work for the same service as me). In a perfect world medicine would work as one cohesive, fine-tuned machine but the reality seems more like everyone is only out to do what work they have to to protect THEIR liability, and everyone else (especially us "non-medical" transporters) will just have to worry about themselves. If he's alert, oriented, non-suicidal, and otherwise competent per my assessment, there's no way in hell I'd do anything against the patient's will unless I either have a court order in hand (for me to keep) or a cop present telling me the patient's in custody. Maybe I read too much into what you were saying, and if so I apologize for sounding like a douchebag, but I just know that I've seen just how little anybody else in the medical world is concerned for covering your ass or making sure that you've got all the stuff you need to avoid being on ass end of a patient encounter. Anyway, the point I'm trying to make is to take everything EVERYBODY tells you with a grain of salt, no matter what organization they're tied to or the letters that come after their name--if you're not already doing that. Second, he jumped from a moving vehicle on purpose. That to me indicates suicidal tendencies. Well, we know he's a diabetic. How do we know that wasn't the cause? Or maybe his labs got all jacked up from the last time he dialyzed? And what exactly do they mean when they say he jumped out of a moving vehicle? If he's a nursing home patient, he's probably not able to get around all that well, so how did he manage that feat to begin with? Finally, just because he was suicidal a couple of days ago doesn't mean he still is. Did he get sent in for eval the day of the incident? If not, why? And if so, what was the conclusion? He's back at the nursing home today, so did they determine he was mentally okay? Again, not trying to bust your balls, but if we just assume that the situation is as the nursing home staff describes, we're putting an awful lot of faith that they have done their jobs and done their jobs correctly. And we weren't there to watch them do their jobs. We weren't there to see if they were swamped with patients that day and didn't get much of a chance to do a thorough job; if they were just having an off day themselves and didn't do a great assessment; or if they just always suck at their job. Third, he is a Psych patient. You would be hard pressed to find anyone that would label someone going into a psych eval as "competent." Obviously, there is a behavior that has been demonstrated to indicate to healthcare professionals that he needs further evaluation. The nursing home staff said he is a psych patient. They're not the emergency medical providers. The only question we should be asking ourselves is, what do WE think is going on with the patient today? Anyway, don't take anything I say personally, and maybe I'm off base here and someone can kick my ass back in the right direction, but I try to approach nursing home calls like any other emergency run. I don't assume that anybody there is competent to give me any sort of information that I mustn't temper with my own findings and judgment, and to a degree I kind of go into every call where I'll be dealing with other medical providers with the mentality that every one of them is out to feed me misinformation, skew my judgment, and harm my patient. Never with the idea that I can trust them to have done everything exactly as I or someone I trust would have, with my liabilities and responsibilities in mind, nor even the highest standards of patient care. Maybe it's wrong, maybe it's not. I don't know. Either way, hopefully this gives you something to think about.
ERDoc Posted October 10, 2012 Posted October 10, 2012 Don't feel bad Beirber, you are pretty much correct. The facility doctor is not YOUR doctor. The only ones you have to follow are your medical director and your medical control. This pt is not a psych pt, whatever that means. You have to assess his situation now. If you can determine that he is not suicidal, homicidal and has the capacity to make his own decision (yes, EMS can do that, it does not take any special degree) then you cannot make him go. The only exception is if there is already a bluepaper, app and cert, 5150 or whatever your local jurisdiction has. If that is in effect then someone else has already determined that the pt lacks the capacity/is dangerous to someone and you cannot override that. If the NH doctor was so concerned he should fill out the proper paperwork and then you can force pt to go.
eb1040 Posted October 10, 2012 Posted October 10, 2012 (edited) Emergency medicine is not often familiar with long term care patients who also present with clinical depression. That impairs one's judgement for making decisions. In this situation the physician must weigh the consequences of allowing a patient to refuse life support treatment such as dialysis. Stopping dialysis should not be taken lightly. Dialysis is too often misunderstood since it is usually just a routine transport without much thought given to its life saving function. Discontinuing dialysis is a major step towards ending one's life and can be seen by itself as suicidal if not made without some discussion. If the patient is in his right mental capacity then he also has the obligation of abiding by informed consent or taking the necessary steps to ending the medical treatment. By he not doing so may demonstrate his limited compacity for understanding his treatments which then makes him irrational and not capable of making his decisions. It is alittle more involved than just telling EMTs he does not want dialysis. In this situation the physician may see it necessary for him to be referred for further medical workup. Even treating a patient for depression has its risks but the doctor must make a medical decision based on past history to determine if this person is really capable of acting in his own best interest. Stopping treatment by not talking with his family, physician and DPOA can be used as justification for a physician's next course of action in regards to medical treatment. A Parmedic is not qualified to determine if a patient should no longer take his medical treatment and end his life. This is not an unusual situation. Health care providers and physicians who specialize in long term care must weigh the odds of patient refusal and medical treatment all the time in hospitals and long term facilities. Without the proper paperwork also done by the patient, a health care provider can not just assist them in killing themselves either especially if their change in compliance is due to an electrolyte imbalance or depression, both of which can be treated at the hospital. This goes beyond refusing one meal or wanting to skip a multivitamin once. If a pattern develops or irrational refusals occurs, then there is more cause for concern with is beyond just saying "No" to an EMT. More often than not these patients can get the proper treatment without a psych hold and that whole unsettling situation especially if they already have a long term illness which requires dialysis. Edited October 10, 2012 by eb1040 1
Just Plain Ruff Posted October 10, 2012 Posted October 10, 2012 (edited) Ok, first of all he has doctors orders. Because they are calling for an ambulance for the transport that tells me he is already confined. Second, he jumped from a moving vehicle on purpose. That to me indicates suicidal tendencies. Third, he is a Psych patient. You would be hard pressed to find anyone that would label someone going into a psych eval as "competent." Obviously, there is a behavior that has been demonstrated to indicate to healthcare professionals that he needs further evaluation. Maybe its my legal background talking but I see this as a non issue. Now, if this was an emergency call and you responded to the scene rather than the hospital you would have to use your judgement based on the totality of the circumstances. As I mentioned in my previous post, per my company we wouldn't transport unless ordered by a mental health professional or a court. I would have no problems transporting this patient because of the doctors order and the history of self harm (jumping from a moving vehicle). Document everything. WOW JUST WOW. Where to begin. I can't seem to get a handle on where to begin because there is so much to digest in this well thought out and intelligent post. But then I read Biebers post and he said it all. But Mike, I suggest you re-read your emt book chapter 1, and then go talk to an attorney about this thread and see what they tell you. You might be extremely surprised to find out that if you were to transport this patient against his will that you would be on the wrong end of the nasty stick of a lawsuit and that EMT cert that you worked so hard to obtain, well it was no longer valid in your state. Psych consults don't necessarily mean that you are incompetent. And doctors orders mean jack shit if the patient refuses transport. The doctor is going to come back and say if you tell him that the patient is refusing to go "well if he's refusing to come then I can't force him". A doctors order is really nothing more than a piece of paper that authorizes transport or a certain procedure to be done. It works really well for insurance because if you don't have the order then it doesn't get paid. The doctors order can't force me to be transported against my will unless there is a whole bunch more paperwork accompanying that order such as a 96 hour hold or a court order. Just because the doctor says transport doesn't mean that you can force the patient to go. Otherwise we'd be forcing many of our patients against their will every single day. AS for the jumping from the moving vehicle, that was 2 days ago, he may have been suicidal then but suicidal thoughts and ideations come and go, he may not be suicidal now. If he isn't suicidal now, then the episode two days ago is just a red herring. It can be used for past history in obtaining the 96 hour hold papers but it cannot be used to confine him right then and there based on that episode. IF so, when I was suicidal 20 years ago, they could confine me today based on that logic. So your thought process and your willingness to transport this patient against his will really scares me, and makes me wonder if you really know the rules of EMS engagement when it comes to this type of patient. It also calls into question how many patients you have tranpsorted against their will just becuase you can. If I was your supervisor and saw this post of yours, I would be in discussion with you behind closed doors trying to figure out whether you had any future at our EMS agency. It also calls into question how many patients who refused care that you transported to the ER against their will who were not suicidal simply because the doctor ordered it. Those being nursing home patients. Do you see what I'm getting at. If a patient says NO i'm not going and they are competent then they don't go unless you can change their mind. Youdon't force them to go like you alluded to in your post. Time for remediation Mike Edited October 10, 2012 by Captain ToHellWithItAll
P_Instructor Posted October 10, 2012 Author Posted October 10, 2012 OK Mike, grab him, strap him, sedate him, take him......get to the psych consult and find out the guy is sane. There goes your so-called pension.
ERDoc Posted October 10, 2012 Posted October 10, 2012 Let's not be too rough on Mike. The legal side of medicine is something that is very poorly covered in EMT/paramedic class as well as medical school. Let's make it a learning experience for everyone. Here in Michigan, a person has to app and certed, meaning that someone has to apply to have them committed and a physician has to certify that they need to be confined against their will. This comes after EMS has brought them to the ER. Before the paperwork is complete EMS/PD/ER have the ability to hold someone against their will if they are a danger to themselves or others or lack the capacity to make their own decisions.
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