police intercede

[paramedicmike]

apparently none of the problems you mentioned existed in this case. if you search patient refusals of treatment, click on page 2, and drop down to comments by medic511, you can read his complete comments. as written, the patient simply didn't want to go, met all the legal requirements for informed refusal, and by law, should have been allowed to sign an ama refusal and go about his business. i wonder what might occur in cases like these if this patient had stood his ground and chosen the squad car and handcuffs? have any lawsuits occured in such cases questioning the authority of police to force a patient to go to the hospital against his will when he clearly (at least according to medic511's run report) met ALL legal requirements for informed refusal as set forth in the law?

Right. Because you can take journalists at face value just like you can take anonymous commentary on a newspaper website at face value.

There is always more to any story. Chances are you'll never know the whole story.

The bottom line is that EMS should not, and legally cannot, force someone to go to the hospital who is otherwise legally competent to refuse treatment. The question becomes one of who is legally competent. Whatever is done on scene by the involved EMS providers should be documented thoroughly.

[BEorP]

If I were the on scene EMT running the call, I'd involve FIRST the OLMC Doctor, with all VS and observations reported. On request, I'd have the Doc talk to the potential patient. Dependent on the OLMC Doc's recommendation after speaking with the patient, I'd either get the Cop witnessed RMA signature, or the Cop's "Protective Custody" for the patient.

Either way, "document, Document, DOCUMENT!"

(Attention "Newbies": OLMC = On Line Medical Control)

Richard, while I accept that this may have been the practice for you, I disagree that this should be the standard way things work in an ideal environment. A competent patient can refuse care. If there isn't an issue of capacity then the patient can make an informed refusal and there is no need to call a doctor. I understand the desire to CYA, but I think that that is a poor reason to make us dependent on calling doctors. If anything, I would think it would be more appropriate to involve an EMS supervisor if you want someone else's name attached to things. But I do completely agree that no matter how it happens, this would need to be documented well, paying particular attention to how it was determined that the patient was competent and how the refusal was informed.

[ERDoc]

Richard, while I accept that this may have been the practice for you, I disagree that this should be the standard way things work in an ideal environment. A competent patient can refuse care. If there isn't an issue of capacity then the patient can make an informed refusal and there is no need to call a doctor. I understand the desire to CYA, but I think that that is a poor reason to make us dependent on calling doctors. If anything, I would think it would be more appropriate to involve an EMS supervisor if you want someone else's name attached to things. But I do completely agree that no matter how it happens, this would need to be documented well, paying particular attention to how it was determined that the patient was competent and how the refusal was informed.

Keep in mind that this is very location dependent, especially when you are talking about the US. In the system I grew up in, if you felt a pt needed to go and they wanted to RMA, you HAD to contact medical control and speak with the doc. It was a volley system so there really were no supervisors like you find in a paid system. I think in this case, you need to justify and document how the patient DOES NOT have capacity.

Edited June 15, 2013 by ERDoc

[mackeydad]

And yes I have used this on the scene to someone that refused transport but did meet criteria through mechanism of injury (only works with men). "If you have injured your spinal cord at all and it is not taken care of you may never have a natural erection again" Works every time

As for the actual post. It is hard to make a good choice just by a forum and not being at the scene. I always encourage my pts to go get checked out, as we do not have x-ray vision to see any injuries. I think in order to answer do we know the outcome. Were there any injuries in the patient?

following the original post by medic511 the patient reluctantly accompanied the medic to the hospital, where a routine ct revealed a significant intracranial bleeding. patient was taken 300 miles by helicopter to another hospital, where a small artery was surgically repaired. patient was released a few days later without significant deficit.

[ERDoc]

The outcome is irrelevant. The only thing that matters in the original scenario is what did the pt want and did they have the capacity to make that decision.

[MariB]

Mackey, I was a former police officer and I encountered this many times as a cop. There are often variables that you are unaware of. Maybe the patient made comments that they want to harm themselves (which you SHOULD be told about but doesn't always happen). Maybe the patient was acting a lot different before your arrival or they are acting different now.

I remember one example where I was the officer investigating a one car MVA with the driver being the sole occupant. Ambulance shows up and starts interviewing the driver who was sober and was for all intents and purposes A&O x4. EMTs were going to AMA him when I interviened. Argument ensued and I basically said something similar to you can go on your own or I will invol you. Patient went to ER on their own and afterwards the EMT's had some choice words for me when I showed up at the ER to complete my report. What they didn't know was I knew the patient and even though he was A&O x4 I knew something was wrong with him. The EMT's failed by asking only standard A&O questions and not going further in their questioning. Had they done so they would have discovered patient was altered. Turns out he had a brain bleed.

So the bottom line is without knowing all the facts, you can't really judge the cop especially when its third party info such as on this forum. However, on the flip side of things, now that I am an EMT I work with our police all the time and more often than not they make me want to pull my hair out and scream. Recently I had a cop get mad at me because I refused to put a suicidal patient in 4 points. I replied to the officer, patient is calm and cooperative for me if that changes I can put them in restraints but you don't arrest people because I tell you to and I don't put people in restraints because you tell me to.

Truth be told police and EMS interaction can be highly difficult.

So you with held your knowledge from the EMTs that you knew he was altered and just took it into your own hands? Just taking it upon yourself to order him to er without explaining why until after the fact?

I would have called your super, had my medical director do the same. You could have endangered my patient with holding what you knew

[paramedicmike]

I have to agree with Mari, Mike. A quick word with the EMS crew could've saved a lot of trouble later. Hell, a quick word with the patient could've saved a lot of trouble later.

You're right. EMS and police communications can be problematic. Your story is a prime example. And it was very preventable.

[MariB]

We don't have that problem really. Our squad has a few police as volunteers. It really helps with the whole police /ems relationship. They see what we do and know when to get out of our way.

Even as a member of our team, had they pulled something like Mike EMT did, there would have been several calls and letters to the Chief of Police.

[BEorP]

Keep in mind that this is very location dependent, especially when you are talking about the US. In the system I grew up in, if you felt a pt needed to go and they wanted to RMA, you HAD to contact medical control and speak with the doc. It was a volley system so there really were no supervisors like you find in a paid system. I think in this case, you need to justify and document how the patient DOES NOT have capacity.

Yeah, I am not at all arguing what we might be forced to do but I just wanted to suggest that this isn't ideal.

[Richard B the EMT]

As always, local protocols rule what you do, and how you do it, at and in your local jurisdiction.

FDNY EMS policy is, if the crew feels the patient should go, and the patient feels differently, OLMC is contacted. I apologize for omitting that OLMC can and will request the nearest EMS field supervisor (usually a lieutenant, sometimes a captain, rarely, but not ruled out, a chief) to respond in. The field supervisor will make the official request, if deemed necessary by OLMC, for an NYPD response, meaning one patrol car with 2 cops, sometimes the Sargent as their backup .

Obviously, if OLMC says to accept the RMA, we do.