Refusal to backboard

[joeboo]

Here is the hypothetical scenario:unsure:


Crew dispatched to independent living facility for possible lumbar injury.

On scene patient lying supine in bed. Pt is roughly 90 years old.

Pt is confused, cannot tell you what year it is, but can tell you her name and where she is. she know's the president is Barak Obama. Basically Alert and oreinted x 2(out of 4).

Pt has possible spinal injury to the lumbar region and claims pain of 5 out of 10.

The fall occurred 2 days ago and she has been up and about at various times since. They finally called the ambulance when they saw the pain was not getting better.

Upon telling the patient that she would be needing to be placed on a backboard, the pt refused, and just wanted to be transported on the stretcher.

Here is the question:

At what point can a patient's mental capacity be overridden to where they lose their rights to refuse treatment?

 

[NYMedic828]

At the point that the crew is not correct in attempting to restrain a 90 year old woman to an uncomfortable board for a fall that happened 2 days in the past.

The lumbar is the thickest strongest portion of the spine. Most "lumbar" injuries are muscular strains/sprains to the lower back. I doubt she herniated a disc doing deadlifts or squats.

The only place I have for backboards outside of blatantly fitting every aspect of the criteria, is as a carrying device.

 

[VFlutter]

Here is the hypothetical scenario:unsure:


Crew dispatched to independent living facility for possible lumbar injury.

On scene patient lying supine in bed. Pt is roughly 90 years old.

Pt is confused, cannot tell you what year it is, but can tell you her name and where she is. she know's the president is Barak Obama. Basically Alert and oreinted x 2(out of 4).

Pt has possible spinal injury to the lumbar region and claims pain of 5 out of 10.

The fall occurred 2 days ago and she has been up and about at various times since. They finally called the ambulance when they saw the pain was not getting better.

Upon telling the patient that she would be needing to be placed on a backboard, the pt refused, and just wanted to be transported on the stretcher.

Here is the question:

At what point can a patient's mental capacity be overridden to where they lose their rights to refuse treatment?

Since your question is specifically asking about mental capacity I will try to refrain from derailing the thread about why you want to backboard a patient who has been ambulatory for 2 days after a fall.

What do you mean by confused? Not knowing the year alone does not really concern me if she can tell you who she is, where she is, and who the president is. Did you ask her what month it was?

When it comes to refusing treatment you need to make sure that the patient understands what you are trying to do and the consequences of not doing it. Did she tell you why she did not want to be back-boarded?

If you explain that the patient may experience permanent loss of sensation, paralysis, and etc and they can verbalize understanding then IMO they can refuse treatment.

 

[firecoins]

No reason to backboard here.

 

[Medic Tim]

pt would be transported in position of least discomfort from me

 

[joeboo]

Thanks for the insight everyone

 

[Clare]

Lumbar pain is not a sign of cervical spine injury. A 90 year old who has been up and about for 2 days and complains no focal neurological deficit, altered sensation etc does not seed their cervical spine immobilised.

I'd either extricate her in the stair chair, or more than likely, directly onto the stretcher.

Remember also that a competent patient has the right to decline treatment; I do not know how you assess competency but here as long as the patient can explain back to you what you want to do and can show they understand what you are telling them and why they do not want it consistently they are competent regardless of outside circumstances.

 

[MSDeltaFlt]

Since your question is specifically asking about mental capacity I will try to refrain from derailing the thread about why you want to backboard a patient who has been ambulatory for 2 days after a fall.

What do you mean by confused? Not knowing the year alone does not really concern me if she can tell you who she is, where she is, and who the president is. Did you ask her what month it was?

When it comes to refusing treatment you need to make sure that the patient understands what you are trying to do and the consequences of not doing it. Did she tell you why she did not want to be back-boarded?

If you explain that the patient may experience permanent loss of sensation, paralysis, and etc and they can verbalize understanding then IMO they can refuse treatment.

Exactly. Your time assessment could have been more accurate. Bare in mind she's NINETY FREAKING YEARS OLD in a nursing home where she doesn't get to go out and about like you and I. Which makes time to become skewed. So she knew who she was, where she was, and why she was. And since she knew some of the current events going on around her, I would argue she knew essentially when she was. Add to that the fact she was aware of the spine board lucidly refused the spine board I would bet she could tell you of possible consequences of refusing making her essentially C-A-O X 4 and verbally appropriate.

Now to derail the thread.

Two questions for you.

1. What clinical presentations were present prompting you to want to board a 2 day post fall?

2. Why would NOT want to board a 90yo geriatric?

 

[mycrofft]

pt would be transported in position of least discomfort from me.

LHS *





(like he said)

PS: I know, you're asking about field determination about mental competence. The easy answer is check your protocols (and if you have one share it!), but your considerations are these:
1. Is this going to lead to a screaming and /or thrashing patient?
2. IS the treatment really necessary? (Call Medical Control...)
3. If the solution is not immediately dire, can you contact a family member, friend or conservator/lawyer or maybe case manager or medical caregiver and advise them what's going on.
4. If the situation is dire, maybe calling law enforcement to at least witness the procedure is a good idea, because stepping over that line (treatment against wishes presuming mental incompetence) can make you a hero, or a lawsuit magnet. Even if you possibly save the pt.

 

[Handsome Robb]

I won't beat the dead horse about the backboard.

If she can reiterate what is going on and is acting appropriately I'd say she's oriented.

 

[zmedic]

You can never go wrong with calling medical control.

"Hi, I have this 90 year old patient who fell 2 days ago, her lower back hurts but she is refusing backboarding which my protocols are directing me to do. I am requesting permission to transport the patient without backboarding her, she has no neuro deficits, and is able to understand the risks of not being backboarded."

Document the MD you talked to. And you are all set.

 

[mycrofft]

LHS too.

 

[Chris07]

You can never go wrong with calling medical control.

"Hi, I have this 90 year old patient who fell 2 days ago, her lower back hurts but she is refusing backboarding which my protocols are directing me to do. I am requesting permission to transport the patient without backboarding her, she has no neuro deficits, and is able to understand the risks of not being backboarded."

Document the MD you talked to. And you are all set.

Assuming as a BLS provider you even have access to medical control. BLS out my way doesn't have that luxury.
Either way this is a no brainer...no board needed. I'd only use the board if I needed a carry device, but I would certainly not use a collar.

 

[STXmedic]

Assuming as a BLS provider you even have access to medical control. BLS out my way doesn't have that luxury.

Uhh... Seriously? :unsure:

 

[Chris07]

If this was a 911 call (which it probably wouldn't be) the responding medics would obviously have access to online medical control (base contact). If this was a private non-emergency call, the responding BLS crew would not have any sort of access to online control.

Besides...We follow the holy ems trinity here at both the BLS and ALS levels. Backboard, O2, and L&S.

Yet another example of why ya'll need to move to Southern California <_<

 

[Christopher]

Pt has possible spinal injury to the lumbar region and claims pain of 5 out of 10.

Not quite. There could be an injury to the cauda equina, but that manifests itself in a different manner than a true SCI. Backboards and c-collars do not immobilize the lumbar region, thus they are never indicated for this purpose.

The fall occurred 2 days ago and she has been up and about at various times since. They finally called the ambulance when they saw the pain was not getting better.

If she was ambulatory in the interim 2 days....I'm willing to wager her injury is stable. If she can walk with it, she can ride on a stretcher.

Again, no indication for a backboard and C-collar yet.

Upon telling the patient that she would be needing to be placed on a backboard, the pt refused, and just wanted to be transported on the stretcher.

Sounds good, don't assault a 90 year old

Here is the question:

At what point can a patient's mental capacity be overridden to where they lose their rights to refuse treatment?

You have to have an indication for the treatment before you seek to use implied consent for a confused patient.

 

[Brandon O]

You can never go wrong with calling medical control.

"Hi, I have this 90 year old patient who fell 2 days ago, her lower back hurts but she is refusing backboarding which my protocols are directing me to do. I am requesting permission to transport the patient without backboarding her, she has no neuro deficits, and is able to understand the risks of not being backboarded."

Document the MD you talked to. And you are all set.

In most cases I would expect the answer to this to be "no," unless you were very good at selling it. It falls under "you wouldn't be asking me this if you knew what you're doing."

 

[Brandon O]

Also, more prosaically, this is exactly how calling medical control can "go wrong" -- you end up putting your doc into a position where he feels obliged to force you to do something that's not in the patient's interest.

Remember that even the best med control physician is not standing where you are, so he's making decisions from a different perspective -- one in which "err on the side of caution" may figure prominently.

View making that CYA call like any treatment: it has potential benefits and potential harms, and you should have a sense of both so you can weigh them in each situation.

 

[Handsome Robb]

If you're truly that worried about it have her sign a refusal of c-spine.

We've got signatures for freaking everything. RMA, AMA, Witness, Privacy, Refusal of C-Spine, Refusal of Trauma Center.

 

[usalsfyre]

If this was a private non-emergency call, the responding BLS crew would not have any sort of access to online control.

What kind of malarkey is this?