Pt refusal, extreme edition...

[DwayneEMTP]

This is an actual patient/scenario of mine. It happened in a Non American country, though in an environment where the moral/ethical/legal rights of the patient and responders are pretty much the same.

Going into this I'd ask us to proceed accepting a couple of assumptions as fact, in the spirit of the intended question. The first that I am at least minimally competent in assessing a traumatic patient, to include an accurate assessment of mentation. The second, that I'm at least minimally competent where getting difficult patients to bend to my will is concerned. In other words, even if you don't believe me competent in those areas, please don't take the easy way out, ("You couldn't do it, but I could have.") in this discussion. See what I mean?

You're dispatched by the comms shack to a 'man with a hurt leg."

Upon arrival you are pointed to a man sitting on a stack of pallets, he's calm, smoking a cigarette, and in good humor. He answers questions quickly, clearly and appropriately. He is aware of all that is going on in his environment, his balance as he sits there is confident. If you could see him from the knees above only there would be no sign that he has any issues at all from your initial impression.

Below the knees however you notice that his left lower leg is being held in place by a 2" diam piece of of lateral skin, the distal lower leg swinging freely. Evidently he's the driver of a truck that's come to pick up some rolls of steel cable. While directing the forklift one of the forks traps his lower leg between it and the palet, effectively amputating the lower limb. The injury is approx. 20 minutes old at this time, bleeding seems to have been limited by the fact that the leg was separated with a crush more than a clean cut, there is very little active bleeding at this time. Sandy/gravel conditions make it impossible to estimate blood loss. Pt rates his pain at 3/10 while looking at his leg and swinging it in little circles as he smokes his cigarette. His only real concern is whether or not it's care will queer the vacation plans that his wife has worked on for two years, set to commence in the next two weeks.

While my partner goes for the cot (trolly, gouney, etc) I lay the patient down, got a good set of vitals, packed the stump with gauze, lined up the lower limb, smashed it into the proximal packing, and tried to hold it all together with a SAM splint and elastic bandages.

When the patient sees the cot coming he immediately says, "I'm not going with you! My wife will be here in a couple of hours, I'll have her take me to the hospital. I'm not going with you, and we both know that you can't make me."

Vitals:

B/P 136/96

P 98

SPO2 99% r/a (sea level plus smoking)

Skins p/w/d

L/S full all fields with only the expected dispersed light wheezing common in chronic smokers.

Described injury the only discovered or reported. Hands/knees/elbows atraumatic.

No n/v, dizziness, drugs/alcohos reported nor suspected.

Unfortunately I've cared for the wound in a rudimentary fashion before the discussion of transport becomes an issue and the patient is convinced that it is more than satisfactory to keep him well until his wife can transport.

I use every argument I can think of up to and including loss of limb and death, even my tried and true, "if you have anyone that you love, or loves you...anyone that depends on you to be a man, then you have no right to act in such a foolish way!" but none so much as makes a tickle in his resolve to wait for his wife. I call his wife, she's two hours out, explain to her that I need to take him now, she talks to him for 5-10 mins, but he won't budge.

I've never really been exposed to such a patient before. I'm comfortable making the argument that he was mentating clearly despite being nearly uneffected by the severity of his wound. Those that have worked around the old time farmers or cowboys can maybe picture this patient...You'll just have to take my word for the fact that you can not legally make the argument later that you took him against his will due to an altered mental status. (You can probably make that argument later and succeed with a CYA tactic, but you can't truthfully make this argument and pretend to stay moral and ethical.)

What do you do? Do you fill out your refusal and leave him? Can you justify this in your service later? If you choose to force him into the ambulance, what legal powers do you use to justify this? What are your moral and ethical responsibilities here?

I look forward to your thoughts...

[scubanurse]

holy cow... any hx of drug abuse or possibility he is on drugs at the moment? I would probably find out whether he would allow IV access, and probably settle in for the long haul with him. If you leave him as is, that's abandonment. Can his employer order him to go? Are you in the position you can sit with him until his wife comes?

You could pull a TV show medic drama and start a line and tell him you're flushing it but load him to 10 of valium and take him once he goes to sleep...

[DwayneEMTP]

Pt shows all of the signs of being a heavy 'off shift' drinker. Thin, sinewy (?), wrinkled face, yellowed nicotine teeth, but also all of the signs of a serious, life long responsible bread winner.

No signs of drugs/alcohol at this time, pupils are PERRL at 3cm, speech is clear and appropriate.

Two far from my area of response responsibility for me to stay with him. Lone medic slot so no one else to cover. Only Local National staff available and they're not qualified for me to hand off to.

Pt refuses IV, and I considered snowing him, I really did, but couldn't justify it morally or ethically.

[scubanurse]

Is he willing to return to your base camp with you?

A little O2 bottle therapy to the cranium?

[DwayneEMTP]

He's unwilling to leave the place where he was injured unless his wife takes him.

[scubanurse]

Grr

[MikeEMT]

Well you could always get law enforcement intervention and force him that way, at least here in US.

If it were me I would try to find out why he doesn't want to come with me and may try to address it that way. Otherwise, not much you could do.

[paramedicmike]

Actually, he could be forced to go. We can compel transport if a patient is a threat to himself or others, right?

It can reasonably be argued that ignoring this injury is a threat to himself. Combine that with the likely shock of a traumatic amputation and even though he may answer questions reasonably that doesn't mean he's competent to refuse.

[island emt]

My concern for this patient is : He is probably in shock, if not pathophysiologically,then mentally. He's not feeling pain and hasn't had the blood loss, but if the original crush tamponade lets go he will more than likely bleed out. . He stands a good chance of loosing the limb if not his life from blood loss or serious infection setting in due to the dirty nature of the wound.

You were in a catch 22 situation, no doubt. You cannot force him , but you also know the severity of the traumatic injury will be possibly life threatening.

My thoughts are: I'm sitting tight until he either tanks or the wife shows up, and I would explain to her the severity. If she's like most wives she will tell him to stop being stupid and go with EMS.

One more thought: without circulation the lower leg will become necrotic in a couple hours time.

Edited January 14, 2013 by island emt

[Arctickat]

Hmmmm, did you ask him why? When I get a refusal I'm not comfortable leaving I usually ask the patient why. Sometimes I have to ask why 5 or 6 times. Everytime I shoot down their reason why with a sound argument until they eventually have no more reasons.

As for Mike's determination, was he knowingly being a threat to himself? I mean we know that the Sympathetic response to trauma is to constrict blood vessels, but once the adrenaline wears off he's gonna start gushing blood...but does he know that? From Dwayne's explanation it would seem that he does know if he didn't before, but still....it's his choice, and no doubt Dwayne did the best anyone could to convince him and inform him of the danger associated with his choice, so, my thoughts, hate it as I might, turn my back and walk away.

Did you ask him if he'd like to record a message for his wife since he'll be dead before she arrives?

Hey Ed, wouldn't the leg still be viable for up to 6 hours? I know in cases of a dislocation with circulatory compromise, we have 6 hours to get the flow returned.

Edited January 14, 2013 by Arctickat