EMS Providers Placing 72 Hour Holds

[Handsome Robb]

The State of Nevada EMS Office put out a survey asking about "appropriately trained" Paramedics placing 72 hour involuntary holds. No action yet but it's a possibility.

What do y'all think about this??

 

[PotatoMedic]

I would want to know what "appropriately trained" means.

 

[chaz90]

What does "appropriately trained" mean for cops placing people under mental health holds? One imagines that's closer to a medical decision than a law enforcement one, even if PD needs to be involved for the enforcement portion.

 

[UnkiEMT]

Largely I'd say it's a horrible idea.

First, there's no way we're going to get enough training to really be able to make the eval for a yea/nay on a hold.

Second, even if they did give us the training, we'll never spend enough time with the patients to really do the eval.

There are, of course, some patients that blindingly obviously need a hold, and I've been doing it long enough that my gut is relatively reliable at picking out the less obvious ones.

Putting someone on a hold, though, is a HUGE deal, and my gut should not be the arbiter, nor should anyone elses, and you're kidding yourself if you think that it won't devolve to the "appropriately trained" paramedics ignoring that training and using their guts (Albeit, the training MIGHT improve the accuracy of the gut reaction). Unlike psychologists, psychiatrists and social workers who typically make the decisions about holds, all of our training is about making a quick decision.

If even one person is put on a hold who shouldn't be, then the entire program is a bad thing, and many more than one will.

PS: Having said all that, a few weeks ago I had a call which wound up being an administrative nightmare, all told I spent 3 hours on the phone, doing paperwork, and meeting with the state EMS office (not to mention pissing off people in four different facilities), all of which could have been avoided if I could have placed the hold. It would have been nice to have the ability, but even still, I don't trust myself with that power, I sure as :censored::censored::censored::censored: don't trust some morons with medic patches I know with it.

 

[UnkiEMT]

What does "appropriately trained" mean for cops placing people under mental health holds? One imagines that's closer to a medical decision than a law enforcement one, even if PD needs to be involved for the enforcement portion.

Everywhere I've worked, though possibly it's different where you are, cops don't place 72 hour holds, they place eval holds, which is, near as I can tell, the least possible restraint available.

The ER places the 72 once they do the eval.

 

[chaz90]

Cops place 72 hour holds in Colorado. Pathetically enough, I don't know how it works here in Delaware yet.

 

[Handsome Robb]

In NV either a LEO, MD/DO, Psychologist or social worker can place a 72 hour hold which we call a Legal 2000.

I agree on wanting to know what the training involves. I know in some areas, such as Texas, LEOs actually get relatively extensive training on the subject. That's word of mouth talking to a friend down their whom is trust with my life.

One of our PDs has a mobile mental health team but the call to resource ratio isn't good.

I also agree that placing a hold is massive. I'd be interested to find out if there could be something similar to an eval hold here but I've never heard of one in 3 years in the field.

One thing I will say is it sounds like it's Paramedic only. We only have a handful of ALS agencies and with that comes a smaller pool of medics. In Northern Nevada, Clark County is another bucket of worms altogether.

I'm interested to know what the "appropriate training" means as well.

 

[Carlos Danger]

Horrible idea. Physically imprisoning a person without clear evidence of having committed a crime is, in the words of our nation's illustrious VP, "A BIG :censored::censored::censored::censored:ing deal".

IMO neither cops or social workers or paramedics/EMT's should not be able to do it. They simply don't have the knowledge, and they aren't going to get it in an afternoon inservice. Only an appropriately trained physician or clinical psychologist should be able to legally determine that a person poses such a threat to themselves or others that they need to be held.

Now forcing someone to go to the psych ED for an emergency eval to determine whether or not they should be held, that's different.

 

[STXmedic]

PD places our 48hr ED holds. All of our city PD officers receive a 40hr "Crisis Intervention Training" which is required to be able to place the ED. Recently, we've been putting a few of our medics through the same course with PD (myself included), just for educational purposes. However, given the same CIT training, I'd prefer the medics place the holds rather than PD.* Occasionally, PD will try and get out of placing a hold despite the patient meeting the requirement and need for it, simply not wanting to tie themselves up or not fully understanding the mental health aspect of the patient.

*Only medics receiving the appropriate training, not just any field medic.

 

[STXmedic]

Horrible idea. Physically imprisoning a person without clear evidence of having committed a crime is, in the words of our nation's illustrious VP, "A BIG :censored::censored::censored::censored:ing deal".

...

Now forcing someone to go to the psych ED for an emergency eval to determine whether or not they should be held, that's different.

Huh? What exactly do you think they're doing with these psych holds? You say absolutely not, but then say its okay for a psych eval. That's the entire purpose of the psych hold... They are forced to the ED to be held for 48-72hrs, or until cleared by a physician. They are not being "physically imprisoned" for any unclear crime...

 

[FLdoc2011]

I'm not sure some of y'all really understand these laws. Each state has different laws and not all allow for this sort of thing but I'm only familiar with Florida's version which is referred to as the Baker Act or BA-52.

Usually these provisions allow for involuntary evaluation by a mental health practitioner. While a police officer, medic or non-psychiatric physician may be allowed to start this, that person will still be evaluated by a psychiatrist or psychologist.

And usually just because you start the process doesn't mean they are automatically held for 72hrs. You may think someone is a danger to them-self or others and begin the process by bringing them in and then they may be seen by a psychiatrist who thinks otherwise and releases then from the voluntary hold.

Here in Florida they are brought in for a medical evaluation and only after they are medically cleared does the 72 hour clock start during which they are either released or a petition filed (by the mental health practitioner) for inpatient placement.

So it could be less than 72hours or longer than 72 hours and the ultimate inpatient involuntary placement isn't done just because you initiate this process. They are still medically cleared by a physician and evaluated by a psychiatrist or psychologist.

Again, each state is different so check your local laws. Here there is much confusion and myths surrounding our process.

 

[STXmedic]

I'm not sure some of y'all really understand these laws. Each state has different laws and not all allow for this sort of thing but I'm only familiar with Florida's version which is referred to as the Baker Act or BA-52.

Usually these provisions allow for involuntary evaluation by a mental health practitioner. While a police officer, medic or non-psychiatric physician may be allowed to start this, that person will still be evaluated by a psychiatrist or psychologist.

And usually just because you start the process doesn't mean they are automatically held for 72hrs. You may think someone is a danger to them-self or others and begin the process by bringing them in and then they may be seen by a psychiatrist who thinks otherwise and releases then from the voluntary hold.

Here in Florida they are brought in for a medical evaluation and only after they are medically cleared does the 72 hour clock start during which they are either released or a petition filed (by the mental health practitioner) for inpatient placement.

So it could be less than 72hours or longer than 72 hours and the ultimate inpatient involuntary placement isn't done just because you initiate this process. They are still medically cleared by a physician and evaluated by a psychiatrist or psychologist.

Again, each state is different so check your local laws. Here there is much confusion and myths surrounding our process.

This is exactly how ours work, with the exception of the hold starting at the time indicated on the ED form, and not after medical eval. That, and ours are 48hrs.

 

[Clare]

Under the Mental Health (Compulsory Assessment and Treatment) Act 1992 it is the role of the Duly Authorised Officer to determine if somebody requires psychiatric assessment.

The DAO is usually a Registered Nurse with specialist post-graduate qualifications in mental health/psychiatric nursing, or there are a few who are psychiatrists or GPs with a specialist post-grad qualification in psychiatry.

The decision if somebody requires compulsory detention or treatment can only be made by a psychiatrist.

To that end, no, I do not support this. Perhaps some specific Paramedics with a postgraduate qualification in mental health could become DAOs but I think it wholly inconceivable that given the almost total disparity between a Paramedic and a Psychiatrist that any sort of custodial powers of involuntary detention be bestowed.

About the only thing in common is that they both start with P.

 

[OnceAnEMT]

I've never seen a 40-72 hr specific time "hold" used in the ED I'm at. If we are holding a psych Pt it is usually because we are waiting for availability at the local psych wards. The only time I'd say there is a specific hold here is when poison control gives us a time frame related to substance OD. Either way, once the "emergency" is cleared, we get rid of them as soon as possible.

About EMS providers being permitted to order such a hold, I disagree. That EMS crew is en route to a hospital of some kind anyway if they are in a position to make that order, so why not just continue to let the MDs make it? What's the "appropriately trained" Paramedic going to do? Go to an ED manager and say "Hey... this guy is going to take up one of your beds for 72 hours. Thanks." I'll tell you now, that would arouse a laugh and a phone call.

 

[DrankTheKoolaid]

Our SMART trained medics can write their own 5150's on patients here in San Mateo county

 

[chaz90]

I've never seen a 40-72 hr specific time "hold" used in the ED I'm at. If we are holding a psych Pt it is usually because we are waiting for availability at the local psych wards. The only time I'd say there is a specific hold here is when poison control gives us a time frame related to substance OD. Either way, once the "emergency" is cleared, we get rid of them as soon as possible.

About EMS providers being permitted to order such a hold, I disagree. That EMS crew is en route to a hospital of some kind anyway if they are in a position to make that order, so why not just continue to let the MDs make it? What's the "appropriately trained" Paramedic going to do? Go to an ED manager and say "Hey... this guy is going to take up one of your beds for 72 hours. Thanks." I'll tell you now, that would arouse a laugh and a phone call.

It's about getting the patient to the ED in the beginning for an eval, not for a dispo once we get there. I used to get exasperated in Colorado on that point. I don't care how long they're placed in a bed or what their psych disposition is from the ED/psych consult, but we need the means to mandate that a suicidal person go into the ED. We constantly fought a battle of PD being reluctant to place their legal hold and fill out paperwork while the ED doc on the radio insisted PD place the hold since they hadn't evaluated the patient yet and didn't want to commit to anything. I don't want or need the power to place people on a 48/72 hour hold. I would like the authority to independently decide certain psych patients must be transported and be able to request the resources I need to make that happen.

 

[OnceAnEMT]

I would like the authority to independently decide certain psych patients must be transported and be able to request the resources I need to make that happen.

Sorry, must've missed you mentioning this part earlier in the thread.

http://wilco.sharepointsite.com/EMS... ORDER 10 2010 Transport Special Patients.pdf

That link details specifically the policy for Wilco, and I believe ATCEMS works the same way. Basically, we don't do "holds". The EMS crews just act stubborn and refuse to accept a refusal, and will stay on scene and illicit all resources necessary to the scene in order to convince the Pt, who has suicidal ideations or is otherwise deemed harmful to themselves or others. PD can do what is called Police Officer Emergency Commitment (POEC), in which given the above Pt who is psych, they can detain them with required/forced consent. These Pts are those who show any suicidal/harmful intent, be it an OD that already happened or a threatening text message.

I believe this is a good system, though of course I'm biased. Because forcing consent is most certainly a legal matter, I feel it is important that PD be present at all times during the process. You can still do your job, you'll just need to have a police officer in the truck as well. Besides, a patient who is forced to go to the ED after refusing will probably still not want to go.

 

[Akulahawk]

Our SMART trained medics can write their own 5150's on patients here in San Mateo county

This is something that is very new. Given that the training is appropriate and thorough enough to appropriately detect whether someone is having an acute mental health problem severe enough to warrant involuntary evaluation, I'm OK with it.

While I generally support the 5150/mental health hold, I don't like it at all from the standpoint of the fact that certain rights are instantly stripped upon application of the hold. This is because there are people that do abuse the power of the hold. I'm not saying that a person shouldn't be held against their will, rather that the other legal ramifications of the hold shouldn't become active until the judicial system is actively involved following a referral from the treating/evaluating psychologist/psychiatrist. There are people that are put on 5150's that evaluated and released because they actually don't have a problem, yet in order for restoration of rights stripped, they have to pay and appeal to the courts because their rights were stripped by a non-judicial process.

Honestly, I don't care who places the initial hold, as long as they're appropriately trained/educated and held to a very high standard of trustworthiness because of the power they're given.

From a "financial" standpoint, once you've been taken into custody you shouldn't be liable for the costs as you're now effectively a ward of the state. Paramedics placing holds should have their holds/runs reviewed so that they're making good mental health decisions and not "financial" decisions for their company...

 

[DrankTheKoolaid]

These are not in an ambulance but a specially dispatched, designed and equipped vehicle.

It's a rather interesting system design that allows them to to avoid the hold and provide and refer to other services.

 

[STXmedic]

From a "financial" standpoint, once you've been taken into custody you shouldn't be liable for the costs as you're now effectively a ward of the state. Paramedics placing holds should have their holds/runs reviewed so that they're making good mental health decisions and not "financial" decisions for their company...

I very much agree with this.