Should We Have Transported...?

[funkytomtom]

Dispatched to a suicide attempt at a local motel, dispatch tells us pt called a hospital and told them he had taken 200 aspirin and was "tired of living." We arrive and talk to pd briefly. Apparently his story has fluctuated between 2 and 200 aspirin and he is now saying he took 20, "just for attention," and has now thrown them all up. We enter the room, and while my other two partners assess the pt, I look around the room and in the bathroom for any pills, pill bottles, vomit, etc. Nearly empty Aspirin bottle and half full vodka bottle found, I re-enter the main room to assist. Pt's vitals are well withing normal limits (I don't recall exact numbers) and stable. He says he never said he was tired of living, but that he said he was "tired of living in this particular place." Pd contacts the hospital to confirm and hospital states that they cannot as there was no recording. I recall distinctly that when the subject of transport was brought up, pt was adamant about not going, and threw the word "lawyer" around quite a bit. We asked him what he was going to do if we left him, and he said he planned on going to work and was not, and never had been suicidal. He did admit to taking 20 aspirin with vodka however, but didn't see that as a suicide attempt, just a try for attention. Crew leader has him sign a refusal and we leave.

I personally consider that a suicide attempt, and was not comfortable leaving this guy alone. The crew was split half and half on taking him in when we talked later. Crew leader says that because there was no hard evidence of suicide on-scene, pt denied, and pd wouldn't take custody, there was nothing we could do. From reviewing my book it seems that this is one of those gray areas where there is no real answer. If we feel he is a threat to himself, we can take him in, although I'm sure this opens us up to lawsuits? Any thoughts?

[letmesleep]

Dispatched to a suicide attempt at a local motel, dispatch tells us pt called a hospital and told them he had taken 200 aspirin and was "tired of living." We arrive and talk to pd briefly. Apparently his story has fluctuated between 2 and 200 aspirin and he is now saying he took 20, "just for attention," and has now thrown them all up. We enter the room, and while my other two partners assess the pt, I look around the room and in the bathroom for any pills, pill bottles, vomit, etc. Nearly empty Aspirin bottle and half full vodka bottle found, I re-enter the main room to assist. Pt's vitals are well withing normal limits (I don't recall exact numbers) and stable. He says he never said he was tired of living, but that he said he was "tired of living in this particular place." Pd contacts the hospital to confirm and hospital states that they cannot as there was no recording. I recall distinctly that when the subject of transport was brought up, pt was adamant about not going, and threw the word "lawyer" around quite a bit. We asked him what he was going to do if we left him, and he said he planned on going to work and was not, and never had been suicidal. He did admit to taking 20 aspirin with vodka however, but didn't see that as a suicide attempt, just a try for attention. Crew leader has him sign a refusal and we leave.

I personally consider that a suicide attempt, and was not comfortable leaving this guy alone. The crew was split half and half on taking him in when we talked later. Crew leader says that because there was no hard evidence of suicide on-scene, pt denied, and pd wouldn't take custody, there was nothing we could do. From reviewing my book it seems that this is one of those gray areas where there is no real answer. If we feel he is a threat to himself, we can take him in, although I'm sure this opens us up to lawsuits? Any thoughts?

Off the topic a little and not looking to split hairs with you, but what is normal in regards to vital signs?

I'd say this pt doesn’t sound completely rational at this point (at least to me, and based on the story). What sane person or rational person is going to drink that much vodka and eat that much ASA, and then admit it was done for attention? Now taking into consideration he is intoxicated, he can be labeled as impaired, therefore unable to make his own decision at this time, which is something that was recently discussed in another thread. I'd say that based on what I have read, I would have transported, but with that said.....I was NOT there.

Anything we do can lead to a lawsuit, but in my opinion, this pt could have been transported. Documentation is your key, and statements about the ETOH consumption, the wavering story about how many pills and what his true intention was will certainly help.

My question at this point is what advice did you receive from your medical direction? Any time you run into situations where you’re just not sure how to handle the pt, call for direction. Part of being good at what we do is knowing when we are stuck and what resources are available to us.

[ERDoc]

This pt should have been forced to go. There is a question of reliability. There is obvious alcohol involved so he may not have the capacity to refuse. Someone who is suicidal will also lie to those who want to help so that they can finish the job. If you are acting the the pts best interest you will (in most cases) be backed up by a court. What's so say this guy isn't going to sign an RMA and then down another bottle of ASA once you leave. By not taking this guy, you have left yourself open to a lawsuit. He should have been forced to go to the hospital where could have been evaluated. His vitals are irrelevant even if they are stable. Most ODs will have stable vitals until it is too late. ASA ods will cause acid-base issues which may not affect the vitals right away. I realize that you were not in charge and your crew was in a shitty position because PD did not want to force him. If this guy tried to leave the ER he'd be in restraints for his own protection. Once the issue of being restrained comes up, pts are usually pretty cooperative.

Long story short, any suicide attempt (regardless of how the pt tries to spin it) should be taken seriously and needs to be taken to the hospital for evaluation.

[VentMedic]

Dispatched to a suicide attempt at a local motel, dispatch tells us pt called a hospital and told them he had taken 200 aspirin and was "tired of living." We arrive and talk to pd briefly. Apparently his story has fluctuated between 2 and 200 aspirin and he is now saying he took 20, "just for attention," and has now thrown them all up. We enter the room, and while my other two partners assess the pt, I look around the room and in the bathroom for any pills, pill bottles, vomit, etc. Nearly empty Aspirin bottle and half full vodka bottle found, I re-enter the main room to assist. Pt's vitals are well withing normal limits (I don't recall exact numbers) and stable. He says he never said he was tired of living, but that he said he was "tired of living in this particular place." Pd contacts the hospital to confirm and hospital states that they cannot as there was no recording. I recall distinctly that when the subject of transport was brought up, pt was adamant about not going, and threw the word "lawyer" around quite a bit. We asked him what he was going to do if we left him, and he said he planned on going to work and was not, and never had been suicidal. He did admit to taking 20 aspirin with vodka however, but didn't see that as a suicide attempt, just a try for attention. Crew leader has him sign a refusal and we leave.I personally consider that a suicide attempt, and was not comfortable leaving this guy alone. The crew was split half and half on taking him in when we talked later. Crew leader says that because there was no hard evidence of suicide on-scene, pt denied, and pd wouldn't take custody, there was nothing we could do. From reviewing my book it seems that this is one of those gray areas where there is no real answer. If we feel he is a threat to himself, we can take him in, although I'm sure this opens us up to lawsuits? Any thoughts?

I would have called for a PD officer with rank or tried to reason with the PD on scene as to why transporting this patient is a necessity.

Regardless of phone record, the patient admitted to saying the same things that activated EMS/LE.

LEOs are generally better trained than this and should have known that people recant their stories when they relize they are being thought of as crazy or know they are about to be held against their will. As well, the officer should be aware that people will lie about what they drugs took. Some patients may also not know what damage the drugs or combo of drugs/alcohol will do if they are altered by the substances and are feeling "good" at the moment. It is extremely important that you document your arguments to PD about your concerns from a medical professional's point of view as they may say they relied on YOUR professional expertise to make their decision. They may even be having this say conversation on the PD forums as "the Paramedics didn't seem overly concerned, should we have been more aggressive?"

The refusal form he signed will also not relieve you of ANY liability because of the very nature of the call and the fact that the patient did admit to behavior that was potentially harmful. It would also be helpful if you got the LEOs signatures on the same form. But, even that still would probably be of little use.

Due to activation of the EMS system for a suicide threat, his comments confirming the threat even if recanted and the physical evidence noticed around him definitely sets you up for legal consequences. If any harm or ill effects come due to what he did on that day, he has a great chance of legal action against you for not having his best interests in mind. As well, his family can come after you later if he is successful at suicide sometime in the future for not getting him help when you had the chance. You had better hope he lives a very long healthy life.

Any threat on one's life should be taken seriously. This is not a grey area at all. The person needs to at least get an eval by a professional who is qualified to determine the extent of the intent since there is enough "reasonable cause" for placing a hold. If the mental health professional determines there is a need to keep the hold, that is their call to make. If they decide the patient is of no threat to their life or to others, that is also their decision and responsibility. In the meantime this is a patient that should be under close observation and possibly restrained in an ED.

Edited September 22, 2009 by VentMedic

[Kiwiology]

I'd never be comfortable leaving soembody in this situation; per our policy if they are expressing or attempting self harm they cannot refuse.

[akflightmedic]

Since the others covered it so well already...all I have left to ask is this:

Where does he work and why was it not shocking to you when he said he would be proceeding to work after drinking that much vodka and pill chasing?

[crotchitymedic1986]

The patient admitted to taking 20 Aspirin, that should have been enough to transport. When all else fails, you should have "medical control" that you can call (local ER Doc if nothing else)to assist you in making the correct decision. In the future, involve a doctor.

[P_Instructor]

Any action, whether deliberate or not, attention getting or suicidal, where there was an attempt to harm self needs evaluation. Force the PD to put them in protective custody and transport him. Let MC know the circumstances also.

[EMT Martin]

Definately a transport. As everyone's said; alcohol really throws out the red flags as far as mental capacity to make the conscious decision to sign a refusal. Furthermore, an attempt at suicide really is an altered mental status sort of area, isn't it? In that regard, there's no capacity to sign a refusal, at all. Add on top of that an altered mental status with the suicide attempt...and you've got grounds to transport. Would've asked the PD to assist and document what happened, as well...for legality's sake.

[VentMedic]

Definately a transport. As everyone's said; alcohol really throws out the red flags as far as mental capacity to make the conscious decision to sign a refusal. Furthermore, an attempt at suicide really is an altered mental status sort of area, isn't it? In that regard, there's no capacity to sign a refusal, at all. Add on top of that an altered mental status with the suicide attempt...and you've got grounds to transport. Would've asked the PD to assist and document what happened, as well...for legality's sake.

The activation of EMS for a suicide attempt with verbal comfirmation and some physical evidence makes this situation very serious and puts question on the patient's intent and mental capacity for making a rational decision. With or without alcohol, this makes this person's decisions suspect and ground for professional evaluation.

The alcohol compounds the issue but is not the sole bases for questioning a person's decision making capabilities. It can either mask or enhance what a person's real intentions are. It is also very possible that this person could sober up and get serious with their intent to kill themselves whereas in their drunken state, they couldn't get it right or other emotions were playing with them. Sometimes being intoxicated actually keeps people from facing reality and killing themselves.

Edited September 22, 2009 by VentMedic