Ok, this should be a fun one.

[Kiwiology]

What's the duration time of Narcan, average? I don't have my Epocrates window open... is it dependent on how much opiate is in the patient's system? (That's for you paramedic/MD type folks... I guess I could go look it up, but I'm really tired tonight!)

I have searched several of my pharmacology textbooks and they do not say, however all warn that it may "wear off quickly" or words to that effect

The data sheet from Medsafe (NZ equiv of the FDA) says that the effects of some opioid may be > naloxone

Wikipedia, MD says naloxone half life is 1.5 hours but has a high (90%) first pass metabolism

[Asysin2leads]

I agree with ERDoc. Once the patient gains mental faculties, and is aware of the health risks and the consequences of their actions, then they have the right to refuse any treatment they choose. The paramedic instructor needs to take it down a peg and maybe a refresher on patient rights and responsibilites. My M.O. would be to call medical control and get the blessing on it, then document the hell out of it and file away under 'possible shitstorms later'. My documentation would include the fact that we strongly and strenuously advised the patient to be transported to the emergency room of his or her choice in addition to performing as through as possible neurological exams and also advised him to call 911 at any time if he changed his mind. Tell the paramedic instructor we mock his value system.

[EMTDenny]

I agree with ERDoc. Once the patient gains mental faculties, and is aware of the health risks and the consequences of their actions, then they have the right to refuse any treatment they choose. The paramedic instructor needs to take it down a peg and maybe a refresher on patient rights and responsibilites. My M.O. would be to call medical control and get the blessing on it, then document the hell out of it and file away under 'possible shitstorms later'. My documentation would include the fact that we strongly and strenuously advised the patient to be transported to the emergency room of his or her choice in addition to performing as through as possible neurological exams and also advised him to call 911 at any time if he changed his mind. Tell the paramedic instructor we mock his value system.

Exactly what should have been done. During the conversation there was no mention of medical control being called.

[DwayneEMTP]

...but maybe they should come up with some kind of protocol, when it is given to the patient they can not RMA....

This is where, in my opinion, you begin to go off into the ditch. First, and foremost, we're patient advocates, right? Why would you want to make even more rules, that will be abused even more than the ones that we have, that would remove more of a patients rights?

We sometimes get caught up in, "But I knew how to help them! I could have made them better!" Making them better is your second priority, the first is making sure that you give them the respect that they deserve for being a human being. I have the right to make self destructive decisions. I have a right to ride motorcycles, jump our of airplanes, drink too much, and yeah, choose a medical course of action that might cause me damage or death. (The exception being my claim that I've put myself there with the intention of purposely hurting or killing myself. For some reason choosing pain and dismemberment on purpose is illegal, doing something that has a high probability of causing the same results, fine.)

If they are awake, and made aware of the dangers, and they had every reason to believe that they were mentating effectively enough to understand those dangers, then there were no legal tools available for forcing them. And there were absolutely no moral tools there, not if your morality is based on patient advocacy.

Having said that, I want them at the hospital, right? I want them monitored so that they will be safe. I personally, as with hypoglycemics, don't believe that they are going to be competent after a few minutes of alertness to make such decisions. So I just don't wake them up. I have a moral and ethical obligation to rescue them from danger, but not one, that I am aware of, to wake them to the point of being able to make self destructive decisions. So I choose to put them in a place where they will have a few hours to make those decisions.

Instead of ending up in this situation, life would have been better for all concerned if they'd just pushed 0.2 of narcan times, however much was necessary, until the patients breathing was adequate and their airway protected and then taken them to the hospital asleep, right?

Even here though, I've taken them without their permission. Saddled them with thousands of dollars in hospital bills. The difference for me is patient advocacy. If I believe that they will wake up and run into traffic, then I'm obligated not to wake them up. If I believe that they will wake up and make alert, though ill conceived decisions, then, in my opinion I'm not obligated to wake them up. But should I wake them up, and put them into a situation where they have moral/ethical/legal rights regarding their own care, then I am forced to comply with those decisions. See? Clear as mud, right?

The highlight of this story for me is that an EMT was fighting management and higher levels of care for a patients right not to be mugged by those that often feel that they don't have to follow the rules because they don't apply when 'you're helping.'

Tell that dude that I want to ride with him for a while...for what that's worth..

Excellent thread man....

Dwayne

...Tell the paramedic instructor we mock his value system.

+3

Edit: I often hear people say that 'they did a refusal because they were lazy.' Has anyone ever worked at a place where a refusal was easier than a transport? Any place that I've worked needed a PCR to explain what you were refusing as well as the refusal documentation. In nearly ever instance I could have transported and been done with my PCR in a shorter period of time. Is this the experience of others?

(The exception being multiple car fender benders where one service only required a name, address, "I've been asked but refused a full exam" kind of statement and a signature.)

[EMTDenny]

This is where, in my opinion, you begin to go off into the ditch. First, and foremost, we're patient advocates, right? Why would you want to make even more rules, that will be abused even more than the ones that we have, that would remove more of a patients rights?

Good point point Dwayne.

[Kiwiology]

but maybe they should come up with some kind of protocol, when it is given to the patient they can not RMA

I'd have to strongly disagree with this. A competent patient always has the right to refuse treatment and/or transport until they are proven not to be competent; somebody who consistently says "I don't want to go the hospital" is competent.

I've seen it might be common for blokes over your way to call the cops and have them put the patient on a psych hold, we do not have such a legal provision here. A patient can only be taken to hospital against their will if they are subject to a compulsory treatment order under the mental health act.

There was considerable debate here about a case in 2005(ish) about a young bloke who'd been belted over the noggin with a 4x2 after consuming a box of cheap beer with the bro's, he walked out of ED after telling them he did not want to be there and ended up dropping dead not long after from some sort of buggery neurogenico. At the end of the day he was found to be in the right because he had consistently told the hospital "I do not want to be here" and that he knew he was at risk of going kaput and dropping dead.

I know we all want to act in the best interest of the patient but there becomes a time when we simply cannot because the patient is free to choose what they do.

Exactly what should have been done. During the conversation there was no mention of medical control being called.

DIE WORDS DIE!

You know I'm thinking the Consultant Emergency Physicians over your way are really, secretly emotionally dead inside and need to have somebody to talk to so they make you blokes ring them up, coz you know the nurses don't like them and the patients cop them a gob full of abuse or complain about not having insurance and such ....

Hang on, Bravo 711 calls Radio, need to talk to the doc .... got us a super mega snafu here, we're not sure if this bloke has been shot or stabbed by gangbangers, there's lots of blood everywhere, um, it's all over my protocol book, help, what doez I do?

Oh and good to hear you volleys are now carrying blood pressure cuffs .... bloody hell

And yes, I'm taking the piss, hmm looks like another case of Piss Takeoccus which is unfortunately resistant to all penicillins, cephalosporins, macrolides and tetracycline antibiotics ... even sulphonylureas but I forget if you give those to people with bacterial infections or diabetes, oh well people with diabetes are more prone to getting bacterial infections anyway so that probably works out right?

Oh and if you call the medical control must you talk with a Consultant Physician or can you talk to the Registrar or House Surgeon? Here if you find yourself in the exceedingly rare situation where you need to seek advice from a Doctor, you must speak with the Consultant, you're not permitted to take advice from the Registrar or House Surgeon. Probably something to do with the fact the Registrar died last week from fatigue and we've yet to find a locum to replace him, and the House Surgeon is dangerously overworked and underfed over in minors putting in sutures or doing rectal exams.

Edited February 24, 2012 by kiwimedic

[EMTDenny]

Oh and good to hear you volleys are now carrying blood pressure cuffs .... bloody hell

And yes, I'm taking the piss, hmm looks like another case of Piss Takeoccus which is unfortunately resistant to all penicillins, cephalosporins, macrolides and tetracycline antibiotics ... even sulphonylureas but I forget if you give those to people with bacterial infections or diabetes, oh well people with diabetes are more prone to getting bacterial infections anyway so that probably works out right?

Oh and if you call the medical control must you talk with a Consultant Physician or can you talk to the Registrar or House Surgeon? Here if you find yourself in the exceedingly rare situation where you need to seek advice from a Doctor, you must speak with the Consultant, you're not permitted to take advice from the Registrar or House Surgeon. Probably something to do with the fact the Registrar died last week from fatigue and we've yet to find a locum to replace him, and the House Surgeon is dangerously overworked and underfed over in minors putting in sutures or doing rectal exams.

Stunning me as always.

I'd have to strongly disagree with this. A competent patient always has the right to refuse treatment and/or transport until they are proven not to be competent; somebody who consistently says "I don't want to go the hospital" is competent.

*scratches that idea from the light bulb notebook." Damn I was seriously going to mention that idea to the right people... LOl just kidding. I have so much to learn.

[Kiwiology]

Nah boss stunning you would be if I whipped out my taser

[DwayneEMTP]

I have a feeling Kiwi that you think that med control is called here regularly. Actually, I don't think that, as we've talked about it a gazillion times, I think you're really just being an asshole...which is why we love you best.

I don't disagree with calling medical control here, though I think that I've only contacted medical control 3-4 times in my short career. Not because you need their advice on what to do, though they may bring a perspective that you've not considered, but so as to be able to document on your PCR that 'you've done everything possible' to convince them to make a better decision.

Wake up an overdose and allow them to refuse without having them talk to the police, your partner, their mom, the hosemonkeys, the neighbor, and yeah, possibly med con, and it could be an issue.

The main point here is that you have to do all that you can to disallow anyone in the future that may be reviewing/judging your decisions from being able to make the statement, "So, you gave them some narcan and then just walked away?" when referring to your now dead, relapsed patient that competently refused care.

Dwayne

[Kiwiology]

I have a feeling Kiwi that you think that med control is called here regularly. Actually, I don't think that, as we've talked about it a gazillion times, I think you're really just being an asshole...which is why we love you best.

Nah bro I was taking the piss, now get your white ass into that water and start swimming down from Kiribati or wherever the fuck you are, we can have a BBQ and get rotten drunk

I am going to start the EMT City treehouse club or something and have a big sign that says "NO EMERGENTOLOGISTS ALLOWED / COMPREHENSIVE DRINKING / KIWI ON DUTY 24 HOURS UNLESS UNCONSCIOUS"

That's a piss take on those signs you see in California which say "Emergency Department / Comprehensive Medical Care / Physician on Duty 24 hours" just in case you were wondering

Edited February 24, 2012 by kiwimedic