Combative Patients Refusing Treatment?

[bigj1130]

Informed consent is a great thing. AAOx3 or 4 can only go so far. If that patient has become a threat to themselves or others we are well within our rights to chemically restrain with IM or IN Midazolam.

A subject can be AAOx3 or 4 and still have evidence of a head injury. In that case do you consider your patient of sound mind and body and able to make their own healthcare decisions? I personally say no and transport them based on Implied consent.

If I have to put them down to do it I will, but I always act in the best interest of my patient. I also have no qualms about restraining a patient for their safety and mine.

Anthony to answer your question about your inebriated person, If I can't talk them down to the bed and he/she is to big for me to put down by myself I will enlist the help of PD or Fire. IF it is too unsafe for us to move him or her to the cot we will give them IM Midazolam and move them after they get a little drowsy.

Lucky don't forget that we as healthcare providers still have to know law. You have to know your consent rules which in some states are law. What powers do we as healthcare providers have in terms of mental health evaluation. Does your state have committal laws? I know that where I work if a person directly says that they want to hurt themselves or others to either PD FD or Us that their right to refuse goes out the window regardless of mental status. I know what you are trying to say but leaving a suicidal patient at home is just as bad as poor medicine. Not trying to start something just saying.

[Richard B the EMT]

I'd first radio for ALS (I'm BLS), for an "ALTMEN" (ALTered MENtal Status) patient. On their interview, would probably contact OLMC, that the patient and Doctor could talk. If the patient refuses to talk, or if deemed needed by the OLMC Doc following the conversation, would request the nearest EMS field supervisor respond. On the supervisor's on scene SitRep (SITuation REPort), the LEOs and a LEO supervisor would then be requested to respond, and put the patient into restraint, and take the responsibility for the patient being transported, against their will, and with at least one LEO in the back of the ambulance with me, to the nearest Psych ER.

Time consuming, yes, but several times over, proven to be needed for the best interests of the patient, in my opinion.

[Richard B the EMT]

I almost forgot: If the patient is violent, I would NOT wait for ALS, Supervisor, or LEOs in the house or apartment, the hallway or sidewalk outside is a safer place for my partner and me. If the patient is in an apartment and damaging things within, screw the equipment if it slows us down, we're going to another floor, and await the LEOs, as the call is now reclassified as a barricaded EDP (Emotionally Disturbed Person), with the LEOs totally in control of what happens to the patient.

Related story: On Sunday, September 28, 2008, a nude EDP, standing on a second story level ledge, threatening the NYPD Emergency Services Officers with an 8 foot long florescent light tube in his hands, was shot with a TASER, causing him to lose his balance, fall to the sidewalk, and hit his head, causing fatal head injuries. An ESU truck with an airbag had not yet made the scene.

As the NYPD protocols were violated (the TASER was used on someone who potentially could have fallen from high enough to get severely injured, and it isn't supposed to be used in that situation), and the pictures made the internet and newscasts from bystanders' cell phone-cameras, all members of the NYPD ESU were ordered to report to the NYPD training facility at Floyd Bennett Field for a refresher class on proper use of the TASERs.

The Lieutenant who ordered the TASER used had been put on "Bow and Arrow" detail, meaning his badge and gun were taken back by the department, and the officer who fired it was now, pending review, "flying a desk".

Yesterday (Thursday October 2, 2008), when the first of the ESU officers started arriving, they found the Lieutenant already there, dead from self inflicted gunshot wounds through the inside of the mouth, with a weapon apparently stolen from another LEOs locker. This was the same day the EDP was buried.

[AnthonyM83]

Thanks for the replies so far.

I also want to emphasize that I'm trying to steer clear of discussion on EMS safety or specific orientation of patient. Assume PD is called if violent. Assume we determined patient unable to make informed decision. Assume not suicidal (refusing life-saving care does not equal suicidal BY ITSELF).

I'm just saying how far do you go? What does it depend on? (Assault with knock out versus bleeding profusely) What legal standing backs you up?

Patient in original scenario didn't want to fight us, but if I had tried to treat or better assess, he would have physically swatted or pushed me away yelling.

[jsadin]

Keep it simple. Call med control and let them decide the appropriate course of action for this patient. That's why the docs make six figures. Some decisions you're better off not making on your own.

[tskstorm]

Thanks for the replies so far.

I also want to emphasize that I'm trying to steer clear of discussion on EMS safety or specific orientation of patient. Assume PD is called if violent. Assume we determined patient unable to make informed decision. Assume not suicidal (refusing life-saving care does not equal suicidal BY ITSELF).

I'm just saying how far do you go? What does it depend on? (Assault with knock out versus bleeding profusely) What legal standing backs you up?

Patient in original scenario didn't want to fight us, but if I had tried to treat or better assess, he would have physically swatted or pushed me away yelling.

Richard gave you the exact rundown of the policies and procedures of our system.

Bottom line is it becomes a judgment call.

Legal protection = Best interest of the Patient. If you're doing whats in the best interest of the patient you're doing something right!

[Happiness]

I just had this call. I am lucky in my point of view as I know almost everyone in my community and have a good repore with my community. When you get this call in the city well that is just a new set of worms.

It is always Mechanism of Injury that dictates what I do. If he is just a nasty person who is intoxicated who was disturbed having a nap by someone who cant tell the difference from a drunk person to some one who is really unconciouse, if they don't want my help then off to jail and don't collect your two hundred dollars. I had this guy and I for the first time in my career said to the cops I will not transport this guy so do what you want to do. It was sad really. I am told that they take them to cells because they cant take care of themselves.

If the pt was a MVA involving drinking and driving then I will ask for police assistance in getting the pt. on a spine board and the spider straps will keep the pt restrained I also will use soft restrains on the board. The cop will be in the back of the car with me.

I have learned in the past few years to use the other emergency resources that are available.

Happy