ETOH Competency?

[Summit]

Pt in a single car rollover without huge damage to vehicle.. Pt ETOH can barely stand, totally smashed, no apparent injuries, but doesn't want treatment. AAO to Person Place Event. Can the Pt legally refuse Tx or Tp?????

 

[MMiz]

Originally posted by Summit@Jan 7 2005, 11:38 PM
Pt in a single car rollover without huge damage to vehicle.. Pt ETOH can barely stand, totally smashed, no apparent injuries, but doesn't want treatment. AAO to Person Place Event. Can the Pt legally refuse Tx or Tp?????

My county protocols say no. A suspected ETOH patient can not legally refuse medical treatment.

And now here comes the after-post edit. If the Pt is AOX3, I would at least contact online medical control, and surely they'll say to take them in.

 

[Margaritaville]

This issue crops up every once in a while. In my state if they are refusing tx, of legal age, and are A x O x 3, they can refuse. Yes ETOH is a hinderance and you must document very well, but let me play devil's advocate here. Remember - this is just for discussion.

If the ED doc says "bring him in", and he refuses what will you do. You do not have police power, you cannot kidnap a patient. The judgement is up to the police. If the ED doc says bring him in, and you do against his will - and there is nothing wrong with the subject besides ETOH - how can the person be forced to pay the ER bill? or the ambulance bill for that matter? What will prevent you from being charged with kidnapping if you did not have the police put them in custody?

This is a catch 22. Damned if you do and damned if you don't. I deal with this issue almost every shift, because of the type of place I work.

Like I said - I am just giving you food for thought, because I have seen this. Your states may be different, but just consider these questions.

 

[rescuecpt]

I find the following statement highly useful:

"You can come with me to the hospital to get looked at, or you can go for a ride to the precinct with that nice officer over there."

 

[Summit]

Originally posted by rescuecpt@Jan 8 2005, 11:04 AM
I find the following statement highly useful:

"You can come with me to the hospita to get looked at, or you can go for a ride to the precinct with that nice officer over there."

This is what happened. The guy wasn't capable of walking to the cruiser though.

Medical control was not contacted (a ranking paramedic took control o the scene and made the decision to accept the refusal).

It seemed odd to all of us (Bs) and to others (Bs and Ps) listening.

OTOH the Pt went straight to the Hospital for a blood draw and then to jail, but a blood draw doesn't mean the guy got c-spine x-rays or anything does it?

 

[Margaritaville]

No summit, it does not mean the guy went for x-rays etc. but this is where you have to let it go. Obviously the patient was in police custody or he wouldn't have been carted off to jail.

Upon going to jail, most precincts will have some type of medical intake if the subject is to be held in custody. If the subject asks for medical attn. the police are obligated to have the subject "cleared" before going back to jail.

This is where the refusal covers on your tail. What happens to that person afterward is not your concern, unless you are called back to them. I know it is a hard thing to do - but sometimes you have to let people make thier own decisions. Just make sure that you do an excellent job at documation and you will be fine.

I had a patient about 8 years ago that made it very clear that she would not go to the hospital. She had chest pain during her weekly poker game. I knew that she was very ill, I explained the possible consequences of her decision, I even resorted to begging because I knew she was a sick lady. She would not budge. Legally there was no recourse. She happily signed the refusal and thanked me for my concern. Two hours later she decided to let her friends run her over to the hospital. She arrested at the ER doors and died. An older paramedic said "honey, you can't think for them - and you need to accept her choice". Know what - he was right. I can't pull rabbits out of a hat, and I am not going to try.

Good Luck

 

[SafetyPro2]

Generally they're given the choice that they can ride with us, or they can ride in the back of a PD cruiser. Yeah, they're gonna probably take a ride in the cruiser later anyway, but at the time that's usually enough of a carrot to at least get them to let us take them in.

FYI, don't know about other areas, but our EMS agency has made A&O x3 the max. They discovered most accident/trauma victims were going to have some loss of recollection of "events prior" and that wasn't necessarily a good indication of ALOC, so now we just check for orientation to person, place and time.

 

[Jon]

Originally posted by Summit+Jan 8 2005, 01:26 PM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>QUOTE (Summit @ Jan 8 2005, 01:26 PM)</td></tr><tr><td id='QUOTE'> <!--QuoteBegin-rescuecpt@Jan 8 2005, 11:04 AM
I find the following statement highly useful:

"You can come with me to the hospita to get looked at, or you can go for a ride to the precinct with that nice officer over there."

This is what happened. The guy wasn't capable of walking to the cruiser though.

Medical control was not contacted (a ranking paramedic took control o the scene and made the decision to accept the refusal).

It seemed odd to all of us (Bs) and to others (Bs and Ps) listening.

OTOH the Pt went straight to the Hospital for a blood draw and then to jail, but a blood draw doesn't mean the guy got c-spine x-rays or anything does it? [/b][/quote]
Out here, if someone is so smashed they can't walk S/P MVA, I'd actaully lean towards to chopper ride to a trauma center, as my local ED will laugh and shake their head no when I call for notification, as the guy wouldn't be CAOx3.


Jon

 

[rescuecpt]

Originally posted by MedicStudentJon@Jan 9 2005, 12:30 AM
Out here, if someone is so smashed they can't walk S/P MVA, I'd actaully lean towards to chopper ride to a trauma center, as my local ED will laugh and shake their head no when I call for notification, as the guy wouldn't be CAOx3.

We're not allowed to fly drunk people here, unless they're totally unconscious and immobile. Otherwise, the flight crew considers it too dangerous. I agree. I've seen drunk people tear up the back of an ambulance - imagine what could happen in a helo.

 

[Jon]

Originally posted by rescuecpt+Jan 9 2005, 07:52 PM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>QUOTE (rescuecpt @ Jan 9 2005, 07:52 PM)</td></tr><tr><td id='QUOTE'> <!--QuoteBegin-MedicStudentJon@Jan 9 2005, 12:30 AM
Out here, if someone is so smashed they can't walk S/P MVA, I'd actaully lean towards to chopper ride to a trauma center, as my local ED will laugh and shake their head no when I call for notification, as the guy wouldn't be CAOx3.

We're not allowed to fly drunk people here, unless they're totally unconscious and immobile. Otherwise, the flight crew considers it too dangerous. I agree. I've seen drunk people tear up the back of an ambulance - imagine what could happen in a helo. [/b][/quote]
Out here, flight crew will come out, sedate, paralize, and RSI anyone they feel isn't stable enough to make the flight without it.

Hey, it works

Jon

 

[NJEMTB]

I work in a city that if you are witnessed walking down the street drunk, the PD calls for the squad and that person goes to the hospital no matter what. If they refuse and fight the officer, they get bracelets and ride to the EC in the radio car. But either way they are going to the hospital. On the other hand, in the town I volunteer in, if the person is drunk the cops won't let you near them unless they have life threatening injuries. They do the transport automaitic to HQ and then after processing they call for the squad. Sometimes I forget where I am riding and I will wonder for a minute when protocol changed. But if a drunk is CA&Ox3 I say RMA them when possible. As long as you document the issue properly, you really can't be successfully sued. The key word there is successfully! Hope I didnt confuse you too much.

 

[Chimpie]

Originally posted by NJEMTB@Jan 9 2005, 10:15 PM
I work in a city that if you are witnessed walking down the street drunk, the PD calls for the squad and that person goes to the hospital no matter what. If they refuse and fight the officer, they get bracelets and ride to the EC in the radio car. But either way they are going to the hospital.

For what good reason would they take a drunk person to the hospital? Tie up the hospital staff who now has to babysit or at least spend some of their time processing this person? Yeah, like their not busy doing everything else. :blink:

 

[Chimpie]

Originally posted by NJEMTB@Jan 9 2005, 10:15 PM
I work in a city that if you are witnessed walking down the street drunk, the PD calls for the squad and that person goes to the hospital no matter what. If they refuse and fight the officer, they get bracelets and ride to the EC in the radio car. But either way they are going to the hospital. On the other hand, in the town I volunteer in, if the person is drunk the cops won't let you near them unless they have life threatening injuries. They do the transport automaitic to HQ and then after processing they call for the squad. Sometimes I forget where I am riding and I will wonder for a minute when protocol changed. But if a drunk is CA&Ox3 I say RMA them when possible. As long as you document the issue properly, you really can't be successfully sued. The key word there is successfully! Hope I didnt confuse you too much.

Ok, maybe I just don't understand your terminology... Is a 'squad' an ambulance or cop car?

 

[rescuecpt]

Originally posted by Chimpie+Jan 9 2005, 10:23 PM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>QUOTE (Chimpie @ Jan 9 2005, 10:23 PM)</td></tr><tr><td id='QUOTE'> <!--QuoteBegin-NJEMTB@Jan 9 2005, 10:15 PM
I work in a city that if you are witnessed walking down the street drunk, the PD calls for the squad and that person goes to the hospital no matter what. If they refuse and fight the officer, they get bracelets and ride to the EC in the radio car. But either way they are going to the hospital.

For what good reason would they take a drunk person to the hospital? Tie up the hospital staff who now has to babysit or at least spend some of their time processing this person? Yeah, like their not busy doing everything else. :blink: [/b][/quote]
In some places, being intox in public is illegal. Lexington, VA for example, if you are underage. You are charged with "posession".

I think they can nab you for it if you are of age as well, but need to have a reason for stopping you in the first place (they can't just snatch you off the street if they have no reason, but if you look drunk, speak too loudly, etc, you're fair game.)

 

[Firechic]

Texas has public intox laws. The person will be arrested, be required to spend a certain amount of time in jail to sober up, and if their breathilizer results are above a certain reading - only then do they go to the hospital.
As far as being onscene and dealing with a highly intoxicated driver, ask the PD if the person is under arrest - if they are, then the police have custody and the responsibility for the patient - they can allow medical attention. If they are a "danger to themselves and others", that could also help in justifying your course of action. It all depends on the situation and the documentation. Yes, there are certain situations where you have to accept the patient's decision (even if you think it is wrong), but when it comes to the real "close to the line" situations (psych patients, ETOH or drug patients) then there is some creative thinking to do (within legal and protocol limits, of course).
Every situation is different.

B)

 

[croaker260]

Weve gotten a little off tract. I think the real question is what makes a person legally able to refuse care?
So what is that?
It means they can make a descision based on UNDERSTANDING information we give them, ASSESSING the risks and benifits both.

to further complicate the issue...Does that right just slip away the moment they take a drink? Or how bout when they cross over 0.05 on the breathalizer? When ?

Simply saying a pt is A&Ox3 is not enough. All that said is they answered who they were (name), where they were (city? Street? planet?) and what time it was (is that GMT? Day time? Night time?)...It's a starting point but now where good enough on refusals. Remember that any soldier in the military can recite his name, unit, and SSN blitzed all to hell...thats on the same neuro-cognitive level as person place and time. They can do it because its a repetive process..doesnt mean they can refuse care.

We need to assess cogninition. This is a general line of questions I use. Done correctly many patients willnot realize you are even assessing their mental status with most of these. I ask these with a smile and a friendly affect.

I start out telling them my name, I ask them to repeat it back to me.. (follow simple commands) and I also warn them I will ask them what it is later. this supplements other neuro tests.
I ask them Person Place and time.
I ask them to spell a 4-6 letter word for me, and then spell it back words.
I ask them how many quarters are in a dollar (abstract visualization)
I ask them to ad 22 and 6 (simple math)
I ask them what they think I am there and what is going on (oriented to situation)
I ask them a question or two about their past EX: Were you in the service?...what did you do?(-Assesses long term memory recall. )
I ask them what my name is (short term memory recall).

Finally I assess the risk to them selves. I try to insure they will not harm them selves and ALWAYS try to offer alternative transport to hospital (friends , family, ect) if they refuse my ride. This I document as well. When reading the chart it changes a 3rd party readers perception from a bored tired medic with another drunk to someone who cared enough to exhaust every option to get the patient evaluated.

Never underestimate the usefulness of Medical control and the cops. Be warned though...

1- at least here, a DOC cannot force you to take someone into custody with out physically evaluating them, and then its through law enforcement.

2- Outside of the hospital, only a PD officer can take a cognitive person in against their will, and thats the PD's interpretation of the law (here it's homicidal, suicidal, or gravely disables...oper to interpretation)

3- Never promise a ride to the jail instead of the hospital with out talking to the PD first...the patient may call you on the bluff. Then your credibility with the patient is shot...and now you job is harder.

 

[Wingnut]

Ok this may be off topic and I'm sorry but at what point do we allow the ETOH (and other non-medical problems) become charge of the SO/PD and not the medics. My husband is a deputy with the SO here and we argue about this all the time. I'd love to prove him wrong...

 

[ffemt8978]

Originally posted by Wingnut@Jan 16 2005, 08:02 PM
Ok this may be off topic and I'm sorry but at what point do we allow the ETOH (and other non-medical problems) become charge of the SO/PD and not the medics. My husband is a deputy with the SO here and we argue about this all the time. I'd love to prove him wrong...

The moment the patient takes a swing at you...

 

[Jon]

Originally posted by ffemt8978+Jan 17 2005, 12:18 AM--></div><table border='0' align='center' width='95%' cellpadding='3' cellspacing='1'><tr><td>QUOTE (ffemt8978 @ Jan 17 2005, 12:18 AM)</td></tr><tr><td id='QUOTE'> <!--QuoteBegin-Wingnut@Jan 16 2005, 08:02 PM
Ok this may be off topic and I'm sorry but at what point do we allow the ETOH (and other non-medical problems) become charge of the SO/PD and not the medics. My husband is a deputy with the SO here and we argue about this all the time. I'd love to prove him wrong...

The moment the patient takes a swing at you... [/b][/quote]
only partially - once the PD goes and beats the guy with batons and he is unconsious, then he is BOTH your problems.

Oh, on a side note, anyone ever heard of PD having someone in custody during an aeromedical flight (talking helocoptor lands on road and cop+DUI driver go for ride)

I guess it would be easy in MD, as the helo staff are all troopers....anyone heard of it happening???


Jon

 

[rescuecpt]

Originally posted by MedicStudentJon@Jan 17 2005, 03:12 PM
Oh, on a side note, anyone ever heard of PD having someone in custody during an aeromedical flight (talking helocoptor lands on road and cop+DUI driver go for ride)

I guess it would be easy in MD, as the helo staff are all troopers....anyone heard of it happening???

Yeah, here too, the helo staff are County PD.

If the person needs to go to the hospital but is in custody, then PD SHOULD be accompanying them.