"Is he competent?". Do you have protocols or informal standards?

[broken stretcher]

In NYS we have Mental Hygiene Law 9.41... basically officer signs a form stating you are a threat to yourself/others and you come in the ambulance... one way or another

 

[mycrofft]

How about this:
1. He or she needs care, obviously.
2. A reasonable person would seek and accept care.
3. Therefore, she or he is not competent.

 

[JPINFV]

there is no reason why the officer cant take the pt to the ED his/herself. I don't have the training or qualifications to go against an officer who believes the person is a 5150.

handover reports are important

Besides the fact that medical care is supposed to be EMS's area of expertise? Psychiatry is a part of medicine. This is also assuming that there isn't another reason for the patient to be exhibiting symptoms that would put them on a hold. Of course 2 weeks ago I got to watch a surgery to dig out two brain tumors from a guy who came in on a hold for grave disability.

 

[JPINFV]

Wonder how that affects things like a pt's ability to grant or deny or withdraw permission for treatment/transport?

A patient on a hold doesn't have the ability to withdraw or grant permission to transport. Any treatment not related to safely delivering the patient to the hospital, on the other hand, is still at the will of the patient. I learned that little tidbit (that patients on holds can refuse care, just not -emergency- treatment and evaluation) during my psych rotation. To override a patient's refusal to, say, take regular psych medications (i.e. their normal dose of anti-psychotics) requires a court order (and, yes, a judge does travel to psych hospitals in California, my local hospital has a court room inside their psych building).

 

[JPINFV]

How about this:
1. He or she needs care, obviously.
2. A reasonable person would seek and accept care.
3. Therefore, she or he is not competent.

So anyone who has an advanced directive is not competent?

A Jehovah's Witness refusing blood transfusion is categorically not competent?

 

[JPINFV]

so it's kind of a moot point as to what the EMS providers think right?

Yep.

yes!!!! if need be, the officer can. He (or she) wants the person committed, he can explain to the ER why it was done, and it was his call.

There's a section on the 5150 for an explanation of both how the call came to the person writing the hold's attention, and another section for the justification. Not that it matters, the ED isn't going to break the hold anyways.

some ambulances do, some done. EMTs do receive SOME training in restraining people... however we can't use handcuffs, and most law enforcement officers recieved MUCH MORE training in restraining people, especially those who don't want to be restrained.

As already mentioned, leather restraints are better than hand cuffs. Also, once the patient is restrained, the need for law enforcement is complete. The hospital doesn't call 911 every time a patient needs to be restrained in the psych unit.

 

[mycrofft]

So anyone who has an advanced directive is not competent?

A Jehovah's Witness refusing blood transfusion is categorically not competent?

Good questions. Are their dependents required to follow their wishes to the point of minors not receiving care if the parent's convictions against are present verbatim or in writing? Can a man say his wife doesn't want care when she is unconscious and needing care?

ENOUGHalready.


Besides trying to bring up the competence/DNR thing from the other direction, I'm interested in actual written protocols and laws. I read a lot about what ought to be done and who ought to do it, but do companies actually have firm written protocols, including or excluding field screening or even core principles, about establishing competence and how that effects care?

 

[Angel]

Besides the fact that medical care is supposed to be EMS's area of expertise? Psychiatry is a part of medicine. This is also assuming that there isn't another reason for the patient to be exhibiting symptoms that would put them on a hold. Of course 2 weeks ago I got to watch a surgery to dig out two brain tumors from a guy who came in on a hold for grave disability.

you're missing my point and that's a great story but I am not a surgeon nor an oncologist.

 

[Handsome Robb]

I'm confused as to the direction this thread went.

I thought we were talking about EMS transporting a legal hold where the provider didn't agree with the hold and there's no medical reason for ambulance transport.

Yes psychiatric problems are a medical problem but is it really the best thing for the patient to slap them with a 1000$ ambulance bill on top of everything else that's going on when they could be safely transported by the LEO who placed the legal hold? Nope. Plus lots of cops think by saying you can go with them voluntarily or me involuntarily gets them out of doing the legal hold paperwork. That is incorrect because the officer is still forcing them to go therefor they need to come to the ER and fill out the paperwork. Even if the patient consents to transport after that.

 

[DrParasite]

As already mentioned, leather restraints are better than hand cuffs.

I agree. but not every ambulance carrys leather restraints.

Also, once the patient is restrained, the need for law enforcement is complete. The hospital doesn't call 911 every time a patient needs to be restrained in the psych unit.

what if the restraints needed to be adjusted? what if the patient escapes the restraints, and needs to be resecured? What if the patient breaks the restraints, and is now swinging at the provider? Will it always happen, probably very rarely, but if something happens as a result of the restraint process, who do you think will be blamed?

And your right, the hospitals don't call 911; they call (civilian) security personnel, who are acting under the doctor's orders to restrain someone, who have completed specilized training in how to restrain someone (or so I have been told by hospital security officers). However, they are still only civilians, and LEOs have much greater legal authority to restrain people.

Oh, and for those who say psych emergencies are a medical issue and require an ambulance, what is an EMT going to do for an EDP that is different than PD? most of the time (unless there are other issues) it's just a restrained transport to the ER. So why not let PD handle it?

 

[mycrofft]

I'm confused as to the direction this thread went.

I thought we were talking about EMS transporting a legal hold where the provider didn't agree with the hold and there's no medical reason for ambulance transport.

The thread started with the question as to whether EMS or ambulance service had actual protocols. SO far I am not actually seeing anything like that.

There is a principle that something is so apparent that the reasonable person does not need a specific warning or instruction, but in a world where we get coffee cups warning us it is hot, and reading about EMTs putting backboards on standing people, I thought someone's service would have something in protocol form:

S/S and complaint=>measures to take=>expected outcome and its indicators.

Is the bigger question this: do you have ready access to your protocols? Are they reasonable and understandable? Are they over three inches thick? :unsure:

 

[JPINFV]

I agree. but not every ambulance carrys leather restraints.what if the restraints needed to be adjusted? what if the patient escapes the restraints, and needs to be resecured? What if the patient breaks the restraints, and is now swinging at the provider? Will it always happen, probably very rarely, but if something happens as a result of the restraint process, who do you think will be blamed?

We can "what if" anything to death. Why not require every ambulance to have an emergency physician on board? After all, what if an EMT or paramedic isn't enough?

And your right, the hospitals don't call 911; they call (civilian) security personnel, who are acting under the doctor's orders to restrain someone, who have completed specilized training in how to restrain someone (or so I have been told by hospital security officers). However, they are still only civilians, and LEOs have much greater legal authority to restrain people.

Where does this extra legal authority come from to restrain individuals for medical reasons? Sure, police can restrain someone when they have reasonable articulable belief that the individual has committed a crime, but we aren't talking about people who are thought to have committed a crime.

Furthermore, if you're doing a transport between, say, an emergency department and a psych facility, do you call the police to restrain the patient for you? Do you require the facility to send a security guard with you?

Oh, and for those who say psych emergencies are a medical issue and require an ambulance, what is an EMT going to do for an EDP that is different than PD? most of the time (unless there are other issues) it's just a restrained transport to the ER. So why not let PD handle it?

Are we arguing that psych emergencies are not medical, or simply that EMS isn't going to do anything? Now, you're right, EMTs aren't going to do much, but hopefully paramedics have chemical restraints.

That said, in every psych thread there's this outright sentiment that "It isn't our job because we can't do anything." There's a lot of transports where EMS can't do anything but vitals and stare at the patient, yet I don't see everyone shouting "fornicate them, let the police transport them since we aren't doing anything anyways" every time it's discussed.

Hey, I guess the person who calls 911 for the nondescript ache for 3 weeks despite 5 cars in the driveway is more of a legitimate patient than the one with the acute psychiatric break. After all, albeit begrudgingly, we're more than willing to transport -that- patient.

 

[Handsome Robb]

We can "what if" anything to death. Why not require every ambulance to have an emergency physician on board? After all, what if an EMT or paramedic isn't enough?

Where does this extra legal authority come from to restrain individuals for medical reasons? Sure, police can restrain someone when they have reasonable articulable belief that the individual has committed a crime, but we aren't talking about people who are thought to have committed a crime.

Furthermore, if you're doing a transport between, say, an emergency department and a psych facility, do you call the police to restrain the patient for you? Do you require the facility to send a security guard with you?



Are we arguing that psych emergencies are not medical, or simply that EMS isn't going to do anything? Now, you're right, EMTs aren't going to do much, but hopefully paramedics have chemical restraints.

That said, in every psych thread there's this outright sentiment that "It isn't our job because we can't do anything." There's a lot of transports where EMS can't do anything but vitals and stare at the patient, yet I don't see everyone shouting "fornicate them, let the police transport them since we aren't doing anything anyways" every time it's discussed.

Hey, I guess the person who calls 911 for the nondescript ache for 3 weeks despite 5 cars in the driveway is more of a legitimate patient than the one with the acute psychiatric break. After all, albeit begrudgingly, we're more than willing to transport -that- patient.

I don't think anyone is arguing that friend.

My point was I'm not going to incur a bill on a patient who refuses to be transported by myself, is medically stable, cooperative so as to not require chemical restraint, why can't the police take that person and save them the 1000$? Give me one good reason.

No, in a situation like that we restrain our own patient with the assistance of security. If they're violent/riled enough for me to feel like a need a second rider and they're going ED -> Psych I'll refuse it and call for PD. Only done that once in 2.5 years. We cannot chemically restrain patients who are going to the psych facility. I generally do not physically restrain these patients either. My words judo hasn't failed me yet. Now they all are told if they give me a reason I will though. Never had an issue with it although it sounds like many places in CA require restraints for a 5150 transport...which is wrong on multiple levels.

 

[Bullets]

There's a lot of transports where EMS can't do anything but vitals and stare at the patient, yet I don't see everyone shouting "fornicate them, let the police transport them since we aren't doing anything anyways" every time it's discussed.

Hey, I guess the person who calls 911 for the nondescript ache for 3 weeks despite 5 cars in the driveway is more of a legitimate patient than the one with the acute psychiatric break. After all, albeit begrudgingly, we're more than willing to transport -that- patient.

Ok, let me be that guy

Fornicate them, lets the cops transport (Done it), or ask whats wrong with the cars in the driveway (Done it), or call our fly car down to do the transport (Done it) or have the patient sign an RMA and then give them a private ride to their doctor or pharmacy (Done it)

If we are going to be taken seriously as a public safety agency, the we need to learn how to say no

 

[abckidsmom]

Besides the fact that medical care is supposed to be EMS's area of expertise? Psychiatry is a part of medicine. This is also assuming that there isn't another reason for the patient to be exhibiting symptoms that would put them on a hold. Of course 2 weeks ago I got to watch a surgery to dig out two brain tumors from a guy who came in on a hold for grave disability.

This is the unpopular stance I take. People with psychiatric problems are patients, not prisoners. If they need extra security on the transport, the cops should ride in the ambulance.

 

[Kevinf]

Furthermore, if you're doing a transport between, say, an emergency department and a psych facility, do you call the police to restrain the patient for you? Do you require the facility to send a security guard with you?

I had a ED -> Psych facility transport last night that I'll share. Walked into the ED to find the patient screaming and swearing at the top of her lungs and pounding on her door (psych room, locked and padded). The door is right at the ambulance entrance to the ED and you can hear her throughout the entire ED. An RN and the head of security come up to us and their first question is... do you have restraints?

We have soft velcro restraints, but we were informed she had already managed to slip out of those. They offered us locking restraints, but being unfamiliar with their gear we were hesitant to use that option. The RN volunteered to ride along to the facility (1 hour+ transport!) with us if we would use them. That option was nixed after the receiving facility was called and stated that they would not accept a patient in restraints.

So here's what happened next. They told the patient that they were going to administer geodon due to her acting out. This upset the patient more and they had two nurses and 4 security personnel enter her room and grapple her to the bed. She kicked the RN and bit a security guard before they managed to get her pinned down and give 20mg geodon IM.

We let her sit for 15 minutes as we had a third EMT called in for the transport. At that point, the meds were kicking in and she had not yet been in contact with us (we were able to observe from outside the room). We walk in and are very friendly to her. She wants out of the ED and is willing to go with us. We get her loaded up, and she was cooperative (and drowsy!) on the ride over with no issues.

 

[SandpitMedic]

Ok, let me be that guy

Fornicate them, lets the cops transport (Done it), or ask whats wrong with the cars in the driveway (Done it), or call our fly car down to do the transport (Done it) or have the patient sign an RMA and then give them a private ride to their doctor or pharmacy (Done it)

If we are going to be taken seriously as a public safety agency, the we need to learn how to say no

I like this guy!

 

[Tigger]

We do not have a protocol for law enforcement involuntary committals, good or bad as that may be.

Our local PD can and frequently does place suicidal ideations/attempts on holds. Even if such threats were only verbalized, we transport them to the ED. PD has a policy not to transport any of these patients ever since the individual has a medical complaint. It takes an exceptional circumstance for an officer to ride or follow with us, most of these patients are cooperative and agree to be transported, though technically they don't have a choice. Even when we do restrain them we're much more likely to bring a firefighter than an officer.

Our county sheriff's office does not issue holds. When it's needed we call our med control, give our reasoning, and then leave it up to the ER doc to issue the hold. If he chooses to do so, we will transport regardless of patient wishes. Again usually without law enforcement present.

Within the next few months we'll be transporting straight to psych facilities which will be a nice change.

 

[DrParasite]

The thread started with the question as to whether EMS or ambulance service had actual protocols. SO far I am not actually seeing anything like that.

we don't, because as I said before, if the cops are making the call, we are just the taxi ride. I can disagree, but if that happens, I will probably have to get my supervisor involved, and their supervisor might get involved, and then it's up to the white shirts to decide what happens.

We can "what if" anything to death. Why not require every ambulance to have an emergency physician on board? After all, what if an EMT or paramedic isn't enough?

then they shouldn't go by ambulance. maybe put an RN or RT if the patient might die? The ambulance should be able to handle what is REASONABLE as to what might happen. if you are taking a person's right to refuse a treatment or transport, and forcing him to accept your actions, is it not reasonable to have an expert in restraining to accompany said person?

Where does this extra legal authority come from to restrain individuals for medical reasons?

Well, if it's on a doctors orders, than I'm pretty sure there is some legal backup to it. but the short answer is, I don't know.

Sure, police can restrain someone when they have reasonable articulable belief that the individual has committed a crime, but we aren't talking about people who are thought to have committed a crime.

no, in this case, they are being placed in protective custody (or your local term), where the officer believes there is an imminant danger to their life if they are allowed to do what they want, and they need to be transported for a psych eval.

Furthermore, if you're doing a transport between, say, an emergency department and a psych facility, do you call the police to restrain the patient for you? Do you require the facility to send a security guard with you?

I haven't done an IFT in years. but the last few times I did transport a violent EDP, I had security restrain the patient to my cot, since they are the experts.

Are we arguing that psych emergencies are not medical, or simply that EMS isn't going to do anything? Now, you're right, EMTs aren't going to do much, but hopefully paramedics have chemical restraints.

Maybe it's just me, but in 14 years, I have never ever seen a paramedic give chemical restraints for an EDP on a 911 call. and I have never see a paramedic or a nurse give a chemical restraint to a psych person during a transport.

The west coast might be different, but I have never even heard of it being done on the east coast

That said, in every psych thread there's this outright sentiment that "It isn't our job because we can't do anything." There's a lot of transports where EMS can't do anything but vitals and stare at the patient, yet I don't see everyone shouting "fornicate them, let the police transport them since we aren't doing anything anyways" every time it's discussed.

Hey, I guess the person who calls 911 for the nondescript ache for 3 weeks despite 5 cars in the driveway is more of a legitimate patient than the one with the acute psychiatric break. After all, albeit begrudgingly, we're more than willing to transport -that- patient.

No one is suggesting that. stop being absurd

Ok, let me be that guy

Fornicate them, lets the cops transport (Done it), or ask whats wrong with the cars in the driveway (Done it), or call our fly car down to do the transport (Done it) or have the patient sign an RMA and then give them a private ride to their doctor or pharmacy (Done it)

If we are going to be taken seriously as a public safety agency, the we need to learn how to say no

saying no? we can't do that.... people want a taxi ride, and we don't require payment. plus they will get seen quicker if they come in by ambulance. plus if we don't transport, we can't bill, and we need all the revenue we can get because we don't get any tax funds.

BTW, I've done all those things except for the last one.

 

[mycrofft]

I had a ED -> Psych facility transport last night that I'll share. Walked into the ED to find the patient screaming and swearing at the top of her lungs and pounding on her door (psych room, locked and padded). The door is right at the ambulance entrance to the ED and you can hear her throughout the entire ED. An RN and the head of security come up to us and their first question is... do you have restraints?

We have soft velcro restraints, but we were informed she had already managed to slip out of those. They offered us locking restraints, but being unfamiliar with their gear we were hesitant to use that option. The RN volunteered to ride along to the facility (1 hour+ transport!) with us if we would use them. That option was nixed after the receiving facility was called and stated that they would not accept a patient in restraints.

So here's what happened next. They told the patient that they were going to administer geodon due to her acting out. This upset the patient more and they had two nurses and 4 security personnel enter her room and grapple her to the bed. She kicked the RN and bit a security guard before they managed to get her pinned down and give 20mg geodon IM.

We let her sit for 15 minutes as we had a third EMT called in for the transport. At that point, the meds were kicking in and she had not yet been in contact with us (we were able to observe from outside the room). We walk in and are very friendly to her. She wants out of the ED and is willing to go with us. We get her loaded up, and she was cooperative (and drowsy!) on the ride over with no issues.

First off, I hope you are ok and the rest of that crew don't develop any nasty nevergetovers.

These sorts of incidents point out that while LE (and especially jail) have protocols, training and tools to address people with mental illness issues in many cases (but not all), EMS and even some hospitals do not.

After three years on the street of 18 hr shifts and 22 yrs with incarcerees, I cannot say how poorly I feel when field people are left to wing it, endangering themselves and their patients. It verges on criminal negligence in my opinion.

Especially new people, don't let yourselves get talked into these sorts of situations without training, tools, and protocols.