Poss ETOH AMS Inside vs Outside

[DwayneEMTP]

If some bloke is PFO (pissed and fell over) it's one of three choices

- Take home

- Leave with the Police

- Take to hospital

If there is somebody at home who is responsible enough for the Ambulance Officers to leave the patient with, off home we go.

If not, then it'd be ace if the Police take him back for detox ... trouble is the Police do not want him just as much as we don't want him.

Should this situation occur then he is left in the hallway on a trolley for a couple hours until he sobers up.

Now, should this guy take a swing at us, vomit all over us, cop me a gob full of abuse or his scrote mates are giving us agro well then he is being left with the Police no two ways about it.

Kiwi you shithead! Haven't you been paying attention? There is no possible way that a competent medical provider can be reasonably confident that a person is simply intoxicated without $20,000 dollars worth of labs and imaging.

Friggin' under-worlders....

Do you all have civil rights and a constitution and all such stuff down there? Or do you..what...go to your village elder and ask them to roll bones or something?

Either way...what would be the local feeling after being taken out of ones home against their will and forced to the hospital for being intoxicated? Assuming that the argument was later made that they were not legally competent to refuse medical treatment and that taking them was necessary to rule out other, possibly life threatening, mimics of intoxication? What would your elder (Laws) say of such a thing? How about your medical morals and ethics?

Truly curious...not just flattering you to try and get you to side with me..

Dwayne

Edited to repair some formatting. No change in content.

Edited June 13, 2011 by DwayneEMTP

[uglyEMT]

I see something being missed here. It seems we are all saying the same thing but missing the BIG picture.

MEDICAL NEED

All the statutes I have seen posted, read for myself, or found online all state "due to immediate medical need". Where is being intoxicated an immediate medical need? Yes if there is something out of wack, findings during your exam, then by all means go with implied consent and do your thing.

I have stated what I would do back on page 1 so I wont rehash it again.

Just keep in mind, MEDICAL need, not just implied consent.

[ERDoc]

I see something being missed here. It seems we are all saying the same thing but missing the BIG picture.

MEDICAL NEED

All the statutes I have seen posted, read for myself, or found online all state "due to immediate medical need". Where is being intoxicated an immediate medical need? Yes if there is something out of wack, findings during your exam, then by all means go with implied consent and do your thing.

I have stated what I would do back on page 1 so I wont rehash it again.

Just keep in mind, MEDICAL need, not just implied consent.

Agreed, but how do you decided if someone is altered simply because they are drunk and not because they are drunk and have had a head injury resulting in an intracranial hemorrhage? I certainly can't tell. Dwayne, I don't think that all who are saying they would take the pt are doing so because of egos or to show how big their balls are. I think it is more defensive medicine, like we see in the hospital. Do you want to risk you certification, career and livelyhood over a drunk? It's funny how no family members care about these people with drinking problems until they dies and can sue for millions. Does it make it right, no, but that is what the legal system has turned medicine into.

[uglyEMT]

Agreed, but how do you decided if someone is altered simply because they are drunk and not because they are drunk and have had a head injury resulting in an intracranial hemorrhage? I certainly can't tell.

Questions, patient history, bystandards, family members, quick trauma assesment,ect.

I see where you are coming from ERDoc, but it is subjective to the provider. Some are straight load and go and on the way get all the history and stuff. I myself would rather get that done on scene and decide if transport is necessary.

I know we live in a suit happy world and anyone would be quick to make a buck but I still believe in personal freedoms too. If the patient doesn't want to leave, all vitals seem normal (minus the etoh), and is not a danger to themselves or others I do not see the need to take them out of their home and to an ED where they are just going to sleep it off on a cot somewhere.

[ERDoc]

Questions, patient history, bystandards, family members, quick trauma assesment,ect.

I see where you are coming from ERDoc, but it is subjective to the provider. Some are straight load and go and on the way get all the history and stuff. I myself would rather get that done on scene and decide if transport is necessary.

I know we live in a suit happy world and anyone would be quick to make a buck but I still believe in personal freedoms too. If the patient doesn't want to leave, all vitals seem normal (minus the etoh), and is not a danger to themselves or others I do not see the need to take them out of their home and to an ED where they are just going to sleep it off on a cot somewhere.

What about the pts where there are no witnesses? I agree, you should collect as much info as you can but with an intoxicated person you need to take everything with a grain of salt. How do you decide if they are a danger to themselves? Being intoxicated automatically means you cannot make proper judgements. There is a reason why it is illegal to drive a car, fly a plane or take care of patients with alcohol onboard.

[Kiwiology]

Do you all have civil rights and a constitution and all such stuff down there? Or do you..what...go to your village elder and ask them to roll bones or something?

Sure do, we have the Bill of Rights Act 1990

In Maori culture they have a Tribal Chief who will often come round after somebody has died at home and remove the bad spirits called Tapu (tup-ew) say if Nana dies it is quite common in their culture.

Either way...what would be the local feeling after being taken out of ones home against their will and forced to the hospital for being intoxicated? Assuming that the argument was later made that they were not legally competent to refuse medical treatment and that taking them was necessary to rule out other, possibly life threatening, mimics of intoxication? What would your elder (Laws) say of such a thing? How about your medical morals and ethics?

If somebody gets PFO (pissed and falls over) at home well then we will leave him there unless we have strong suspicion he needs to be seen at the hospital. If he does not meet our criteria for competency (being pissed would exclude him) we call the cops to give us a hand getting him to go, or have the cops take him.

[fiznat]

It's clear that there must be an emergency need. This does not give you the right to take them to rule out a medical need.

What?!? What's the difference Dwayne? Altered mental status is an emergency medical condition!! You think you can diagnose the problem in the field, and yet you call ME arrogant... Take a look a few posts down buddy- even the emergency room physician says he can't do that. How do you suppose you can?

And even then you can see that this doesn't apply to you unless you get instructions from your medical director...

Another basic EMS concept for you: everything we do as paramedics is done under the licence of the medical control physician. That's why there are only "standing orders" and "direct orders." There's no such thing as "do what you want under your own license." Paramedics can't do that. Like it or not, we paramedics are nothing more than an extension of a physician license. Take away the physician, and you can't do a thing. The law is VERY relevant and absolutely does apply.

Also, as I and others have mentioned, but you again choose to ignore, there are plenty of drunk people, in their own homes, that we can reasonably assume are just going to sit and drink. We won't save them from that, we have no realistic belief that there is a stroke hiding behind the booze, nor do they claim to be a danger to themselves or others other than by possible acts of stupidity, which is not limited to those that are shitfaced.

I don't even understand what you are trying to say here. Are you are proving your point by saying that there are potentially sick people who we haven't met yet? So the whole concept of implied consent fails in your mind because someone, somewhere, must be drinking alcohol?

...where the Doc and nurses will ask what's wrong, determine without all of the fancy tests that have been argued are necessary for every dizzy or altered person, and then send them home, often walking...

So you KNOW what they're going to do at the hospital? How sure could you really be about this? Are you willing to gamble the patient's life on it? ...Or do you see it not a gamble at all, because your paramedic assessment and 10 minutes at the patient's side are plenty for you to make up your mind? Again, you call me arrogant.

this document does not make your case then you insult me and everyone else that takes the time to read it.

Disagree.

Your attitude from the start at, "This thread is a waste of time." through, 'this is so obvious I can't believe I'm even coming back to it" have been insulting and arrogant.

Well I'm sorry you feel that way, but I really do think that it is obvious. This is a basic concept that I utilize if not on a daily, at least a weekly basis during my work as a paramedic. What's more, I feel that your solution is potentially dangerous, and will lead to poor outcomes for both you and your patients. Sorry if you feel my response to you was too strong, but honestly dude I just cannot see where you are coming from. My intent wasn't to be rude.

What you posted doesn't apply to the situation. The calls that the thread was addressing, at least past Lone Stars post, related to people alert, but not legally able to sign a refusal. I was exhausted from asking you to prove your point, something that in the past you'd seemed to relish doing. I wasn't going to respond to the cited document because it was so obviously not relating to anything in this thread.

I just don't get it. The posted citation doesn't apply at ALL? You honestly can't see any connection whatsoever and it didn't even deserve a reply??? I simply cannot believe that. Either you are being purposely obtuse or you're not reading the same document I am.

What is maybe even sadder is that the two best, most intelligent posts in this thread came from LS and Ugly, neither ALS providers. Pretty smart shitheads though...

And why would that be sad? This is a basic concept that both EMTs and medics need to understand. It has nothing to do with whether or not they took a 1,000 hour paramedic training course. Careful what you say-- some EMTs might take offense that you think they can't contribute to a discussion like this.

At least if you can't listen to me, listen to the doctor:

Agreed, but how do you decided if someone is altered simply because they are drunk and not because they are drunk and have had a head injury resulting in an intracranial hemorrhage? I certainly can't tell.

Being intoxicated automatically means you cannot make proper judgements. There is a reason why it is illegal to drive a car, fly a plane or take care of patients with alcohol onboard.

Edited June 13, 2011 by fiznat

[DwayneEMTP]

...What?!? What's the difference Dwayne? Altered mental status is an emergency medical condition!!

No man, altered mentation is an assessment value, that like most assessment values mean very little on it's own. The fact that you call altered mentation an emergency all on it's own...well, that's weird to me..You better call hypertension/tachycardia an emergency as it can be a sign of stroke and cardio pathology...,oh...wait...the patient fell down while jogging.. A single assessment value tells you almost nothing.

...You think you can diagnose the problem in the field, and yet you call ME arrogant... Take a look a few posts down buddy- even the emergency room physician says he can't do that. How do you suppose you can?

Before you get all uppity again, please quote where I claimed to be able to diagnose this issue in the field? I simply claimed that a person alert enough to refuse should be able to be assessed to a point where you can be reasonably confident that they are simply intoxicated and at that point you should not drag them out of their house against their will. The entire point of your argument is that a person should be required to remain in a constant state of being legally competent even when in their own home, right? I'm calling bullshit on that...You shouldn't violate a persons Civil Rights just to cover your ass.

...Another basic EMS concept for you:

Thank goodness I have someone as wise and experienced as you to pass on first week basic concepts to me..I might not have been able to practice without you...

... everything we do as paramedics is done under the licence of the medical control physician. That's why there are only "standing orders" and "direct orders." There's no such thing as "do what you want under your own license." Paramedics can't do that. Like it or not, we paramedics are nothing more than an extension of a physician license. Take away the physician, and you can't do a thing. The law is VERY relevant and absolutely does apply.

Wow, you mean we work under that license of a physician? When the fuck did that start?? Now you're just trying to be foolish...I made it very clear in my post that the part of the document you posted made it very clear that it was addressing PHYSICIAN LEVEL ASSESSMENT/DIAGNOSTICS. Contrary to what you may believe, you are not a physician. But you continue to do what you've done this entire thread, which is skip the questions and arguments that make you think/give you issues and continue to beat the same ol broken drum.

...I don't even understand what you are trying to say here. Are you are proving your point by saying that there are potentially sick people who we haven't met yet? So the whole concept of implied consent fails in your mind because someone, somewhere, must be drinking alcohol?

No idea what this means.

...So you KNOW what they're going to do at the hospital? How sure could you really be about this? Are you willing to gamble the patient's life on it? ...Or do you see it not a gamble at all, because your paramedic assessment and 10 minutes at the patient's side are plenty for you to make up your mind? Again, you call me arrogant.

I've never done a 10 minute assessment on a patient I considered refusing. Stops doing load and go calls and maybe you'll have time to learn to do medicine.

...Well I'm sorry you feel that way, but I really do think that it is obvious. This is a basic concept that I utilize if not on a daily, at least a weekly basis during my work as a paramedic. What's more, I feel that your solution is potentially dangerous, and will lead to poor outcomes for both you and your patients. Sorry if you feel my response to you was too strong, but honestly dude I just cannot see where you are coming from. My intent wasn't to be rude.

My intent has been obvious from the start, you seem to be the only one in the thread unable to see it. You should not be able to drag someone out of their house against their will without a good reason or a definable emergency. You have no right to take someone from their home against their will to r/o any possible occult pathologies. And even then not without being able to cite the legal power that you're using to do so. You've failed to do so on every count.

...I just don't get it. The posted citation doesn't apply at ALL? You honestly can't see any connection whatsoever and it didn't even deserve a reply??? I simply cannot believe that. Either you are being purposely obtuse or you're not reading the same document I am.

I mean, it applies as it mentions physicians and taking away someones rights, but it doesn't apply to us. AGAIN, the document makes it clear that it is referencing physician level assessment/diagnostic! Man...Please tell me that you're just trying to be difficult here and that you're not really confused by two or three paragraphs of clear language?

...And why would that be sad? This is a basic concept that both EMTs and medics need to understand. It has nothing to do with whether or not they took a 1,000 hour paramedic training course. Careful what you say-- some EMTs might take offense that you think they can't contribute to a discussion like this.

No idea where this came from. Some of the biggest balls on this site are owned by non medics.

...At least if you can't listen to me, listen to the doctor:

I did...the doc said that you are practicing "defensive medicine." I agree, and said so about 300 posts back. Defensive medicine, in this subset of patients, is not patient advocacy medicine if by that we mean that you will protect a patients right to control their own destiny along with their health. We are always tasked with patient advocacy first. You can disagree, the doc can disagree, the rest of the world may disagree but I will never purposely damage a patient so that I can cover my ass. Something that you claim to do "if not on a daily, at least weekly basis" and through post after post after post you've failed to define the legal power that gives you the right to do so....and that's pitiful.

Shoot, I'm sorry this has gotten so rough, but truly man, I've admitted that I've seen your point of view, I haven't missed it, and kind of get it, even though I think that it's scared medicine/pt advocacy, but have simply asked that you show the legal precedent that you use to justify your actions and you haven't done so. Why is it so hard for you to understand that I am offended that you feel justified removing free people from their homes against their will when they've broken no laws and yet you are unable to cite the legal morals/ethics that allows you to do so?

The most insulting part of this whole thread, in my opinion, has been that you pick the posts apart. Answer the questions that you believe fortify your cause and simply ignore anything asked or said that you find troublesome. I'm not sure if you're scared to be proved wrong in this debate, just lazy, or if at some point you've been damaged and lost your ability to read critically, but I know you used to have it.

Unfortunately we've scared most everyone else off so it's hard to know what the other opinions hold.

Dwayne

Note: Having to run so posting without rechecking this like I should but don't want to wait several hours to post. My apologies for any errors.

[fiznat]

A single assessment value tells you almost nothing.

BS. VF on the monitor means almost nothing? Absent respiration means almost nothing? An open femur fracture means almost nothing? I understand where are you are coming from, but there are some clinical signs that simply can't be ignored. A persistent heart rate of 250 cannot be ignored. A blood sugar of 1000 cannot be ignored. ALTERED MENTAL STATUS cannot be ignored!!

I made it very clear in my post that the part of the document you posted made it very clear that it was addressing PHYSICIAN LEVEL ASSESSMENT/DIAGNOSTICS.

From the law I posted:

...consent to surgical or medical treatment or procedures, suggested, recommended, prescribed or directed by a duly licensed physician, will be implied where an emergency exists...

My contention is this: we as paramedics work under the purview of a physician, and perform interventions that may reasonably be construed as "directed by" that physician. That's what protocols are-- an extension of the physician's direction for our care. The law states that "consent...will be implied" to carrying out those orders "where an emergency exists."

You state that I have failed to demonstrate that an "emergency" exists. Thankfully, this law goes as far as to define an emergency:

...an emergency is defined as a situation wherein, in competent medical judgment, the proposed surgical or medical treatment or procedures are immediately or imminently necessary and any delay occasioned by an attempt to obtain a consent would reasonably jeopardize the life, health or limb of the person affected, or would reasonably result in disfigurement or impairment of faculties.

That seems pretty clear to me. In "competent medical judgement," (notice: NOT specifically the judgement of a physician, but rather the much more general term "competent") the proposed treatment (in this case- transport to a hospital) must be "immediately or imminently necessary." Maybe this is where we differ. If I walk onto a scene and find a patient who is so altered that he or she is unable to have a coherent conversation, a patient who couldn't possibly understand what is going on - never mind comprehend the risks of a refusal - I feel that transport to a hospital is immediately and imminently necessary.

Why? This is a patient who is exhibiting signs and symptoms of a myriad of potentially life threatening conditions, which I am absolutely unable to completely separate from much more benign causes. I DON'T KNOW if this patient is "just drunk," or having a huge head bleed. The presenting condition and the result of my assessment could just as easily point to either cause. There is absolutely no objective clinical basis from which you can determine that this patient is not experiencing a time-sensitive critical medical emergency. I don't care if you spend 10 minutes or 60 minutes at the patient's side. It just can't be done. ...So how can you honestly determine with any certainty that transport isn't "immediately or imminently necessary??"

You talk a lot about patient advocacy. You are confronted with a patient who's clinical presentation suggests that he or she may possibly be experiencing a severe, life-threatening emergency. You have no way of ruling that emergency out, and the patient is incapable of a coherent conversation. What does the patient advocate do? Does the advocate err on the side of caution and get that condition ruled out, or does he hope for the best and accept an illegitimate and legally indefensible refusal so that he can head back to the station bunk room?

I've never done a 10 minute assessment on a patient I considered refusing. Stops doing load and go calls and maybe you'll have time to learn to do medicine.

You're right, load and go isn't the answer. How many minutes does it take to rule out a head bleed in this patient? Serious question.

You should not be able to drag someone out of their house against their will without a good reason or a definable emergency. You have no right to take someone from their home against their will to r/o any possible occult pathologies.

I disagree. And so do the states who have passed the laws I cited. Ruling out pathology is an absolutely critical step in managing any emergency. This isn't just some random, healthy looking dude we picked up out of a crowd. This is a patient with profound altered mental status, who is so incoherent that he can't even understand what you are saying to him.

And even then not without being able to cite the legal power that you're using to do so. You've failed to do so on every count.

Disagree again. See above.

I mean, it applies as it mentions physicians and taking away someones rights, but it doesn't apply to us.

Dude. It applies to procedures "recommended by" a physician in an emergency as defined by "competent medical judgement." Direct quotes. Are you really saying that the things you do in the field are not "recommended by" your medical control, and are not the result of "competent medical judgement??" Explain that one to me.

Defensive medicine, in this subset of patients, is not patient advocacy medicine if by that we mean that you will protect a patients right to control their own destiny along with their health.

Defensive medicine is equally in defense of patient's lives as it is provider's careers. I consider that to be advocating for the patient.

Edited June 14, 2011 by fiznat

[DwayneEMTP]

The entire thread, post LSs post, has been about patients that are alert enough to verbally and physically refuse transport..

You win man. I'm not smart enough, or have enough time to try and block every bullshit rabbit trail you can create for each time you get jammed up.

Thanks for the discussion.

Dwayne