Patient sign off....then she was dead 6 hours later

[remote_medic]

Just venting...sharing.

Did a call 2 days ago for a early 20's female having a seizure. Grandmother reports she was "thumping" against the wall. On our arrival she is awake, sleepy but appropriate. Known seizure disorder on Dilantin. She is acting ok but annoyed that we are in her bedroom at 530 am, wants us to leave her alone to sleep. She refuses to go to hospital. Vitals stable, she signs our refusal form. Up walking when we leave

Well, just after noon oclock we are on another call when the call goes out to the address we were at at 530. "female not breathing". Spoke with the crew who responded and they say she had riggor. No resuscitation attempted. Medical examiner case now. Come to find out the girl has a history of drug use and suicide attempts in the past.

While I don't feel responsible, I feel bad. Spoke with my service director and the EMT (many years of experience) on the original call. We all feel the first call was handled appropritely. Just a good reminder why we need to be very thourough with our sign offs. Fortunately we use an electronic run report so I can type as much as I want to in the narrative.

We will see what the report is from the medical examiner.

 

[BossyCow]

I recall a medic digging frantically through the garbage can for a strip he ran on a pt. Was a pickup & dustoff call from a frequent flier who was found dead on the toilet he was helped to the night before by caregivers the morning after...

"No.. he was fine! I Swear! I have the tape!"

The tape was found.

 

[Ridryder911]

Hopefully, your patient report presents that the patient fully understood the risks and not that she was postictal and confused. Also that the Grandmother would assume care of the of the patient.

R/r 911

 

[remote_medic]

Hopefully, your patient report presents that the patient fully understood the risks and not that she was postictal and confused. Also that the Grandmother would assume care of the of the patient.

R/r 911

Sure did, fortunately I have the habbit of "over doccumenting"...at least that's what my coworkers call it.

 

[EMTCop86]

Sure did, fortunately I have the habbit of "over doccumenting"...at least that's what my coworkers call it.

I am sure your coworkers will be grateful when that "over documenting" saves yours and maybe their butt one day. Rather be safe then sorry.

 

[Tincanfireman]

When I run a medical call at the full-time job (airport), the usual length of any narrative I write will be ~8-10 typewritten lines, be it a skinned knee or cold/flu. I'll let you figure how long the AMS and MVC narratives can run. I have grown used to the jibes from my "2-3" line co-workers regarding my exhaustive writing, but our legal counsel has mentioned to me that if we ever have to go to court with a case, he hopes it's a call I responded to. Keep doing what you're doing and remember that ink is cheaper than a good defense lawyer.

 

[Onceamedic]

I'm sorry remote medic. That can't be an easy situation for you. In NO way do I think you did something wrong. The thing I am going to try and take from your experience is the knowledge in my gut that if they call - I am going to haul. While this policy does not make me popular with my partners (kinda like your "over documentation") one of these days they will be grateful. At 2:00 am it is pretty tempting to leave them at home with a refusal. I know that there are cases of "incarceritis" where I have shortchanged the assessment. This is not what I get paid for. Thank you for posting about this experience. It will help anyone that takes a lesson from it.

 

[WuLabsWuTecH]

i've noticed that my run reports get shorter and shorter as time goes on. When i was fresh out of school, I was writing dissertations, but now some of them are only about a paragraph handwritten.

This is true of the longer shifts as well

 

[remote_medic]

The thing I am going to try and take from your experience is the knowledge in my gut that if they call - I am going to haul.

Maybe I wasn't clear earlier, but the patient refused transport...I didn't refuse to transport her.

I can not take a patient against his/her will. That would be kidnapping.

 

[Onceamedic]

Maybe I wasn't clear earlier, but the patient refused transport...I didn't refuse to transport her.

I can not take a patient against his/her will. That would be kidnapping.

Yes.. that would be kidnapping. I'm sorry if I didnt make it clear that I didnt think you did anything wrong.

 

[joncrocker]

Execellent job on reviewing the call. All to many will go around thinking it was their fault or that they could have done more.

 

[rhan101277]

If they are in a postictal state isn't that considered implied consent? Granted this women wasn't in such state, but I just wanted to make sure. Since she would have an altered mental status.

 

[sharpenu]

I am not saying this was what you did, but we all know that there are medics out there that guide patients to refusing care. "You don't really want to go to the hospital for this, do you?"

Medics get in trouble from accepting refusals all the time, but I have never heard of a medic getting in trouble for taking someone to the hospital.

Postictal patients are considered to be incapable of accepting or refusing care.

Again, I was not on your call so I am not saying that you did anything- I am just throwing out some food for thought.

 

[BossyCow]

If they are in a postictal state isn't that considered implied consent? Granted this women wasn't in such state, but I just wanted to make sure. Since she would have an altered mental status.

I have left many postictal pts at home, but not home alone. For someone with a known seizure disorder, the postictal phase is something common and ordinary. I've stayed on scene long enough for the pt to reach A&Ox3 and then allowed them to sign the refusal.

 

[mycrofft]

Roger that Bossycow

The time between event and recovery is part of the eval, since it can reasonably be anticipated that a segment of this population may progress to a life threatening state. Sort of like a diabetic you give sugar to and then they are much better...untyil that sugar spike reverses and powerdives. Sometimes you gotta move slow and think/observe.

 

[aussieemt1980]

We have a refusal of treatment / transport form that we complete and have a witness or the pt sign, that contains the advice that we gave. We also have one for head injury as well.

By the sounds of it, you did all you could to get the patient off to hospital, but at the end of the day we cannot force the patient. It can be hard, with thoughts that you may not have done enough, but the decision of the patient is final.

Don't tear yourself up over it. We lose too many medics who burnout over the matters of consent and the consequences of the patients decision and it would be a big issue in the US as it is here.

I had a patient once who came off a motorbike and had another one ride over his lower back. We responded, transported to a clearing post (motorsport event), and arranged for transport for possible internal injuries. Before transport arrived, the patient declined transport. As part of my advice, I told the patient to attend the local ED if he is not feeling well over the next 48 hours, and I found out a week later from the pts father that he decided to attend the local ED and was admitted to the nephrology unit due to kidney injury (he was urinating blood).

The father thanked me for recommending the hospital, as what was back pain and external bruising resulted in his son being put on standby for emergency surgery.

I always cover myself by recommended attendance at the local GP or hospital if the symptoms do not subside or get worse. (Remember the panadol commercial - if pain persists see your doctor?)

 

[remote_medic]

A follow up for anyone who cares...

Cause of death was ruled suicide by intentional overdose of multiple perscription and non perscription drugs.

 

[RESQ_5_1]

I recently had to go to court for a pt that was charged with DUI of cocaine. As a result of my well written PCR, I was able to accurately detail what I found, how I found it, and everything pertinent to the call. I don't think there could be such thing as over-documentation.

 

[crotchitymedic1986]

This is why i am against leaving patients at home, until the day we have the ability to do labs and xray. Which isnt to say you did anything wrong, but there is just no way to rule out every possible diagnosis with the limited tools we have.

Think about it this way: A 14 year old girl comes to the ER for dyspnea, after breaking up with her boyfriend. She is obvioulsy hypeventilating, and everyone knows it, and treats her accordingly. But they will not discharge her until they do a blood gas to confirm hyperventilation. If the ER doc will not discharge her without supporting lab work, I do not understand why we feel so comfortable to not transport this same patient to the ER.

 

[BossyCow]

This is why i am against leaving patients at home, until the day we have the ability to do labs and xray. Which isnt to say you did anything wrong, but there is just no way to rule out every possible diagnosis with the limited tools we have.

Think about it this way: A 14 year old girl comes to the ER for dyspnea, after breaking up with her boyfriend. She is obvioulsy hypeventilating, and everyone knows it, and treats her accordingly. But they will not discharge her until they do a blood gas to confirm hyperventilation. If the ER doc will not discharge her without supporting lab work, I do not understand why we feel so comfortable to not transport this same patient to the ER.

Wow, so all your patients have good insurance eh? I am not going to transport a stable pt with no significant mechanism of injury and no obvious signs of symptoms of disease unless they insist on it. For example, wife calls 911, says husband quit breathing, we show up, husband is awake, conscious and talking to us. Says he suffers from sleep apnea and fell asleep in a chair, he swears he's fine and wife over-reacted. Skin color is good, all vitals WNL, EKG shows NSR, O2 sat in high 90's am I going to make this guy go to the hospital and spend the next several hours being told that he's okay after every test in the book? No, we're going to chuckle over his wife's nervousness, shrug off his apologies and tell him its all in a days work and we're going to have him sign a release, document the heck out of it and tell him to call us if he needs us again anytime.

Sending this pt to the ER just to cover my posterior is a waste of the ERs time, the pts money and the taxpayers dimes.