Self harm patient refusing transport

[ExpatMedic0]

Hey,
I am curious as to what everyones policy/protocol is for self harm patients refusing transport.
For example, a patient who is GCS 15, alert aware and is denying future intent to harm himself or others. However, the patient has either self harmed or attempted suicide before arrival.

Transport is Kidnapping or implied consent? "consent" based on the patient's best interest since they have demonstrated recent inability to make rational choices regarding their health and personal safety?

 

[Chewy20]

If they tried before our arrival, PD will more than likely put them under the 72 hour mandatory hold and we will transport.

 

[Clare]

Just because a patient has self-harmed or is expressing thoughts of suicide does not make them incompetent to make decisions however it does "muddy the water".

The assessment of patients expressing a desire to commit suicide is beyond the scope of ambulance personnel. They require a psychiatric assessment by a professional with psychiatric expertise. This is the job of the Duly Authorised Officer under the Mental Health Act. The Duly Authorised Officer is either a specialist psychiatric nurse or a psychiatrist and is part of the community mental health crisis team (CAT).

Briefly, if it is possible for CAT team to assess the patient in the community and there is a competent adult to remain with the patient then transport to hospital is not required. However, if it is not possible then the patient must be transported (usually to ED) and ambulance personnel can restrain or sedate the pt to achieve this, or use the police for assistance.

Most patients I've come across in this situation are quite willing to be helped and the police are not required. Some patients do not react well to the police and they are more of a hindrance. The police have powers to detain people for risk of self harm or suicide however I have only seen this once, it's far easier to convince people to go to ED which is nice and warm rather than the police cells which are pretty depressing looking.

 

[Underoath87]

It would be LE's job to place them on a psych hold. Then you can haul them off to the ER without issue. We would not attempt to transport them against their will otherwise.

 

[HWhite98]

Good information here but the true answer will ultimately depend on local protocol. In general a patient who has attempted suicide needs some kind of professional attention. More often then not the police will place the patient into protective custody and will assist you and transporting the patient to the hospital. At least that is how my protocols are.

 

[Tigger]

My agency is a subcontractor for the state provider of "mental health crisis response." As such, we work with these patients to have them agree to be transported by a single paramedic to the "crisis stabilization unit" in Colorado Springs. The CSU is like a freestanding pysch ER that tries to find definitive care for these patients. We medically clear them (the usual H+P, EKG, BAL, and saliva drug test), and then we'll take them down there. We try and not place these patients on a hold as the CSU can provide more options without the burden of a 72 hour mental health hold.

If the patient does not wish to use this resource, we'll ask them to reconsider and bring up the fact that being transported to CSU is a far cheaper alternative than the ambulance and ED bill. If they still don't want to go, we may have PD place the patient on a 72 hour old. However, city PD covers a portion of our district and the sheriff's office will not write holds. Should that be the case, we'll call the hospital and have the physician place the patient on a hold. If I can't call the hospital, I am allowed to use my judgement to bring the patient if I think they are an imminent threat to themselves or others.

 

[PotatoMedic]

I want a system like that. With a good crisis center.

 

[NomadicMedic]

My agency is a subcontractor for the state provider of "mental health crisis response." As such, we work with these patients to have them agree to be transported by a single paramedic to the "crisis stabilization unit" in Colorado Springs. The CSU is like a freestanding pysch ER that tries to find definitive care for these patients. We medically clear them (the usual H+P, EKG, BAL, and saliva drug test), and then we'll take them down there. We try and not place these patients on a hold as the CSU can provide more options without the burden of a 72 hour mental health hold.

If the patient does not wish to use this resource, we'll ask them to reconsider and bring up the fact that being transported to CSU is a far cheaper alternative than the ambulance and ED bill. If they still don't want to go, we may have PD place the patient on a 72 hour old. However, city PD covers a portion of our district and the sheriff's office will not write holds. Should that be the case, we'll call the hospital and have the physician place the patient on a hold. If I can't call the hospital, I am allowed to use my judgement to bring the patient if I think they are an imminent threat to themselves or others.

This is the most logical crisis/EDP protocol I've ever seen.

 

[Flying]

@Tigger

Just. Wow!

 

[Tigger]

It is awesome. Most of these patients require neither an ambulance ride nor a visit to the ED. We've done it enough that we now feel comfortable sending the "alternative care transport vehicle" along with law enforcement to these scenes. In the event that there is an additional medical component, the ACT vehicle still has a full compliment of ALS gear to get things started while awaiting an ambulance.

The CSU people are just the bomb too. We can call them to get the patient outpatient help if that's a better course or arrange for us to take the patient straight to an inpatient mental health facility should the patient have already been there. Or if the patient is intoxicated we can take them to detox and CSU will come get them for an evaluation once they have sobered up.

It helps the EMS system as well. During the day we staff four paramedics and one EMT (soon to be all medics). So if we get a psych call, we send one paramedic, leaving two full ambulances. In the past, that would take a full ambulance, so if we went three calls deep we could only send an ambulance with one paramedic aboard and hope that we could cajole a driver.

 

[Jim37F]

Unfortunately we're limited to, as Dierks Bentley so elloquently puts it: "five-one, five-oh, someone call the po-po"

 

[Clare]

Sounds similar to how the community mental health service (CMHS) works here.

There is no requirement to transport people to ED to get a psychiatric assessment as the CMHS can come and see them in the community and if there is a competent adult to watch the pt until this happen this means ambulance personnel are not required to wait with the pt either, can give whoever is remaining with the pt a copy of the PRF and leave. The CMHS can transport them to wherever they need to go to; either to ED or inpatient facility, some of which are freestanding within the hospital grounds and some of which are in the main hospital building. In theory, if got the GP involved and they were willing, the pt could be taken to their GP practice and have CMHS meet them there. Never done that, never heard of it being done, but the option is there as well If the pt has a good relationship with their GP this is not a bad idea I do not think.

I would much rather resolve something by getting the pt assessed in the community rather than involve the police. I like the police, but they tend to complicate matters sometimes. Even just the sight of the police being there will often be enough to freak people out.

I'm really uncomfortable with the idea of ambulance personnel or the police being able to order detention of somebody for a specific period of time. The law here states a person can be held for up to six hours to obtain a psychiatric evaluation. The reason I say I am uncomfortable with it is the proper evaluation of psychiatric patients is far beyond the scope of ambulance personnel or the police. Noting seventy-two hours is mentioned, what happens if this person is evaluated by a psychiatric specialist say, two hours after, and determined to be suitable for release back into the community, what happens to the other seventy hours that Joe Bloe the ambo or Constable Bloggs signed him up for?

 

[luke_31]

Sounds similar to how the community mental health service (CMHS) works here.

There is no requirement to transport people to ED to get a psychiatric assessment as the CMHS can come and see them in the community and if there is a competent adult to watch the pt until this happen this means ambulance personnel are not required to wait with the pt either, can give whoever is remaining with the pt a copy of the PRF and leave. The CMHS can transport them to wherever they need to go to; either to ED or inpatient facility, some of which are freestanding within the hospital grounds and some of which are in the main hospital building. In theory, if got the GP involved and they were willing, the pt could be taken to their GP practice and have CMHS meet them there. Never done that, never heard of it being done, but the option is there as well If the pt has a good relationship with their GP this is not a bad idea I do not think.

I would much rather resolve something by getting the pt assessed in the community rather than involve the police. I like the police, but they tend to complicate matters sometimes. Even just the sight of the police being there will often be enough to freak people out.

I'm really uncomfortable with the idea of ambulance personnel or the police being able to order detention of somebody for a specific period of time. The law here states a person can be held for up to six hours to obtain a psychiatric evaluation. The reason I say I am uncomfortable with it is the proper evaluation of psychiatric patients is far beyond the scope of ambulance personnel or the police. Noting seventy-two hours is mentioned, what happens if this person is evaluated by a psychiatric specialist say, two hours after, and determined to be suitable for release back into the community, what happens to the other seventy hours that Joe Bloe the ambo or Constable Bloggs signed him up for?

Lots of areas have it setup that the psychiatrist can remove the patient from the hold as soon as they determine that the patient doesn't need the care.

 

[CALEMT]

If they tried before our arrival, PD will more than likely put them under the 72 hour mandatory hold and we will transport.

This. If PD wasn't on scene prior to out arrival, we would call PD for a 72hr hold.

 

[ExpatMedic0]

Thanks for the feedback everyone. Sounds like most of you use police holds or have a community mental health team which can assist.

 

[TransportJockey]

For us, pd wont put them on holds (in nm it doesnt exist) but the geberal practice is if they are a threat to themselves or others, they get tra.sported since it shows they cannot make rational decisions. Now that I'm reading this, I need to research some more. No idea how the new job does it

 

[Tigger]

I'm really uncomfortable with the idea of ambulance personnel or the police being able to order detention of somebody for a specific period of time. The law here states a person can be held for up to six hours to obtain a psychiatric evaluation. The reason I say I am uncomfortable with it is the proper evaluation of psychiatric patients is far beyond the scope of ambulance personnel or the police. Noting seventy-two hours is mentioned, what happens if this person is evaluated by a psychiatric specialist say, two hours after, and determined to be suitable for release back into the community, what happens to the other seventy hours that Joe Bloe the ambo or Constable Bloggs signed him up for?

They can be held for up to 72 hours but it rarely takes that long. The 72 hours gives enough time for the patient to sober up (if needed), be evaluated, and have a facility found for them for further care. Once the patient arrives at their destination facility, the staff there may choose to put them on a longer hold requiring the patient to remain in the facility for a certain amount of time. EMS and law enforcement have no say in this process, and nor should we.

If we mess up and the patient is not actually a risk to themselves or anyone else, off the hold they go.