Mental Status Exam documentation

[CBEMT]

Anyone have something like a Mental Status Exam form, or protocols you might have that specifically spell out who could be allowed to refuse transport after, say, a hypoglycemic episode or suspicion of ETOH intoxication? I know its something that should be in every run report, and it will be, but this will be more to establish a guideline for transport/no transport in the absence of established protocol rather than the subjective judgment of the provider in charge.

It sound silly and I wish I could explain further without compromising what anonymity I have, but unfortunately that's what I can give you. What it comes down to is a that transporting nearly all of these patients to the ER (as desired by regulatory body) is conflicting with the possibility that departure from established precedent would lead to a fear of calling EMS in the first place, and thereby increasing risk of serious injury or death to our population. We're trying to strike a balance that would satisfy everyone involved.

Thanks!

[Chief1C]

If they are fully conscious, aware of their surroundings, respond with out thought to questions, answer questions appropriately; able to walk (if that applies), stay alert; I'd let them refuse. Of course if they're intoxicated, and can't do any of this, and still refuse.. PD will help them change their mind.

[mstovall]

We require that a person be ANO x 4 (person, Place, time, and events leading up to us being called). If we don't have a good feeling about something due to ETOH or drug related, and certain BH's, LE is informed and we stay on scene until we get their blessing to leave (this is done as a witness to the refusal form).

Michael

[CBEMT]

To clarify, this is not an EMS safety concern. This is to establish a consistency among personnel for transport/no transport decisions.

Some of the factors being considered are patient surroundings and safety if allowed to refuse, medications, availability of friends to help the patient home if necessary, etc. Like I said a lot of factors here given our setting that I can't really get into publicly that complicate the situation.

[Richard B the EMT]

If the patient is alert as to who they are, where they are, when they are, and the one not in my protocols but I'm going to use anyway, aware of whatever events led the 9-1-1 system to be activated for them, and I still have doubts, the protocols I operate under then require contact with the On Line Medical Control physician. My partner and I give recommendation as to if the patient really needs to be seen by higher medical authority, or not, and most times the Doc will speak directly with the patient.

If the OLMC Doc is unable to communicate with the patient (deaf, language barrier, other), OLMC will request dispatch to send a "conditions boss" (field lieutenant, or higher ranking supervisor, if closer), for an "eyes on" evaluation of situation, and update OLMC. If needed, THEN the LEOs are brought in to place the patient into "protective custody" and "on their authority" the patient is transported to the Emergency Department.

Of course, if the crew, the supervisor, and the OLMC agree with the patient that they do not need to be seen, OLMC will advise the crew to accept the RMA (Refused Medical Assistance).

In all cases requesting RMA, OLMC must be contacted if the patient is under 5, or older than 60.

[CBEMT]

Sounds good, but if I called OLMC every time I had a questionable drunk they'd never give me another order as long as I lived. And no offense, but I have a hard time believing that NYC ER docs have nothing better to do than chat with BLS trucks about mind-altering substance abusers. :wink:

Besides- I am the conditions boss, and I'm already there because I came with the ambulance.

Nevermind that in the time it would take to run that procedure to it's conclusion, I could have dropped that patient off at the ER and be transporting the next one to join him (short transport times at this job :wink: ).

I know you didn't write it and I'm not saying it doesn't work for you, though I don't understand how- it just wouldn't work here. Thanks though.

[Richard B the EMT]

1) "Questionable Drunks" are placed under NYPD's protective custody, and they go to the hospital, cuffed, if the LEOs feel it nessesary.

2) The FDNY EMS has a small office in Maspeth, from which we have our OLMC. It is not even in a hospital. We have agreements with a few hospitals to act as backup OLMCs, should call volume get too large, or the rarity of not having a doctor (multiple reasons) actually at the department's own OLMC.

[CBEMT]

I was hoping your OLMC was from that sort of set up, but I didn't know for sure. I figured it would have to be for that large of a system. Do crews ever catch flak from receiving physicians who don't like the orders given by the EMS OLMC?

[Richard B the EMT]

Do crews ever catch flak from receiving physicians who don't like the orders given by the EMS OLMC?

Probably.

I'd speculate the ER doctor would be given the OLMC phone #, and advised to speak to the control doctor. If I were a paramedic, I'd dial it myself, explain to to my control doc, then pass the phone to the ER doc, and let them discuss.

[Arizonaffcep]

Here is the guideline that EMS providers use in Southern Arizona. It's spelled out rather nicely...seems like one of the things we've done right!

http://www.saems.net/Downloads/PatientRefusalTransportSO.pdf