Obtaining consent for C-spine

[JPINFV]

Depends on their mental status prior to RSI. I've yet to perform a truly elective RSI, and yet to do one on a patient who could be deemed competent. I could imagine a scenario with a burn patient, and yes we should get consent.

Arguably elective vs non-elective procedure is irrelevant if the patient has capacity. No capacity, than it's implied consent and it doesn't matter. However, even the critical patient with capacity has the right to refuse treatment, even if that treatment essentially ensures the patient's death.

 

[medicdan]

What makes you say this? Sometimes it doesn't happen... sometimes it always happens.

Because I think it's extremely difficult to properly explain the risks of a procedure, beyond, "Things might go wrong, including a worsening of your condition. If complication occur, they can range from X to death." Even if you include statistics on rates of complications or adverse events, I think it's too difficult for an individual to quantify and comprehend the relative odds and risks of these decisions. I truly don't think we (medical professionals in general, but especially physicians) do a good enough job explaining these possibilities in emergent and elective situations, but I also have doubts it is even possible.

 

[Brandon O]

Brandon, I think if you actually give the speech as you wrote it, you're setting yourself up.

"So here's the thing. You can either have ice cream and cake which is really pretty good. I'll give you a ride over there my minivan and after the cake and ice cream we can go swimming over at my house. Or I can put you in a cardboard box, sealed up with masking tape, throw a bunch of ping-pong balls and then take you over to my house and feed you roasted beets and brussels sprouts. They say that brussels sprouts are a lot more healthy than cake, but they taste like crap and you're probably not gonna like them. So, which one will it be?"

I think if you explain it without the negative bias, you'd be much more apt to be able to withstand any legal or QI issues that may arise out of your C-spine deferral.

First of all, thanks for the laugh; I like your version.

You could adjust the speech, of course, and it would probably behoove one to iron out the details beforehand (although handing people a pre-printed consent form might be a bit much). But I'm not sure whether, in the end, this solves the problem.

Imagine asking your medical director or clinical boss whether you should do this (or perhaps they track you down because you already have). "Should all our EMTs start obtaining informed consent prior to routine C-spine on stable, competent patients?" The instinctive answer is probably "eek," right? But why?

Many providers probably aren't sufficiently familiar with the evidence to be able to accurately describe risk/benefit. And if they did, they might not be able to appropriately communicate them to people while they're lying on their bathroom floor.

This is tricky, because with most of us operating under a protocol-based system, consent isn't the same consent that a doctor obtains. In principle, we're saying, "I think the most appropriate care might be XYZ -- here are the risks and benefits -- what do you think?"

In EMS, we're not recommending anything. In fact, half the time we might not think something is particularly smart. But our protocols tell us to do it. So what we're actually saying is, "I'm going to do XYZ [because my boss said so]; if you won't let me, then I'll stop." That makes it difficult to have a back-and-forth about benefit, because in essence they're indirectly arguing with whoever created your protocols, not you. It's similar to patient refusal of transport -- I once had to transport a kid who got a beesting, because he wasn't old enough to refuse, and it didn't matter whether *I* thought he should go, since my opinion doesn't matter.

So I think what's under the surface for the People in Charge is really that they don't want patch-wearing peons asking patients whether they want to submit to protocol-defined treatment, based on peon-defined data. And this is fair in some ways. But it would be difficult to tell a provider NOT to do this without essentially saying, "We don't allow for informed consent." So if you suddenly started churning out high percentages of patients refusing C-spine, well... many places you'd probably find yourself out of a job for some vaguely-defined reason like tardiness or insufficient boot polish.

You could also argue that for an old lady lying on her floor, it's not fair to expect them to weigh NNH figures and whatnot. You could even argue that, as DEMedic suggested, almost any way of describing these factors will end up sounding like a "talk-out," merely because there's evidence against the practice and little evidence for it. Of course, maybe that's just how reality is; at some point, trying to be "fair and balanced" means trying to evoke a rationale which doesn't exist (or which really amounts to, "it's just to cover our butts.") What if your CQI person says, "Yeah, I think the way you describe it is probably biasing them?" Unless you're getting signatures on pre-printed consent documents, it's hard to argue against that.

What do you do if they ask what YOU'D do? I'd tell them the truth, which is "no collar, thanks." What I'd do for my mother? Same. But what do I recommend for them? I can't really say, can I? No more than I can tell someone they don't need to be transported.

 

[hogdweeb]

Thats a horrible policy that begs for a lawsuit.

why I said "honestly". Fire department hasnt had many good SOP/SOGs for a while.... like 17 years. it all needs to be erased and re written from scratch.

 

[TheLocalMedic]

Interesting thread. I recently had an experience that made me raise an eyebrow regarding this kind of thing....

Guy overturned his pickup after getting rear-ended on the highway (traffic was moving pretty slowly though). Found him sitting on the shoulder denying any injury besides and abrasion on his elbow. Some CNA was gripping the guy's head like it was about to fall off and refusing to let go, even when he was asking her to "get off" and "let go". I was able to talk her into finally releasing her grip and gave the guy a quick once over and determined that there was definitely no need for any kind of c-spine precautions.

Right about then the BLS fire dept showed up. They immediately grab the poor guys head again, throw him on a board and start strapping him down. I tried to explain that I was an off-duty medic and that the patient really was fine (which the pt was also repeatedly trying to tell them), but they more or less ignored me and kept on strapping away.

Then the ambulance pulls up. And here's what really blew me away... without even saying a word to this guy they just pick up the board, put it on their gurney and load him into the ambulance. The whole time this poor guy is saying "I really don't think this is necessary, I'm not hurt!" But nobody was listening to him.

So yeah... I don't know about giving a whole spiel about the pros and cons of backboarding, but I do think that maybe people ought to listen when someone is trying to say STOP or NO.