Pt refusal, extreme edition...

[Just Plain Ruff]

Hey all, sorry so long to respond.

Medical control wouldn't be a realistic option in this environment. I do have medical control that I can call but they're either in Singapore or Sydney. They don't have much idea what goes on in environments that we work, they are primarily for medical advice, maint of company policy compliance, and helping to arrange medivacs. They would have been happy to speak to him, but the likely outcome would have been that he'd've refused to follow their instructions also, and they may have demanded that I take him against his will, something that I would have refused to do, the refusal of which would have possibly been terminal to my continued employment with this company. So I didn't see any up side to involving them.

I did consider talking to his employer, but he's also, like me, employed by a company that's outside of the country and subcontracted to a trucking company in country. They might have helped, if getting past the language barrier was likely, which it wasn't, but more than likely once notified they forgot about him and were on the phone demanding to know when replacement truck driver would arrive.

I didn't follow up with him, but my guess is that they amputated the leg and he went on his vacation as planned. He would have needed to be medivac'd to Brisbane or Cains for any chance for reattachment efforts, and he would almost certainly not have made it to either place for 24-48hrs.

Again, like I said, I believe the guy knew what the local hospital was going to do to him, he's seen it before or knows friends who have lost legs or arms. He saw no reason to make the inevitable come any faster.

And for everyone on here who tried to overlay their medical control onto Dwaynes situation, this location to my thoughts is completely different than anything that we are used to.

Dwayne, good job in a difficult situation.

[Bernhard]

Dwayne, this is a tough call and you did well.

My own experiences are not to be compared due to setting, but my arguments may have included (and a lot of them are already mentioned):

• Sometimes it is helpful to make really clear, that the patient is able to decide and you will give him the freedom. This will take a lot of stress out of the situation, since sometimes people aren't open for arguments when they think, they have no choice anyway.
• "Why did you call us in first place?"
• showing the severeness of the wound - literally. Expose the injury and give a sound explanation. I have this a lot with drunks, bleeding all over from a cut in their forehead or such, ignoring that they should get a trip to the hospital. Since a while we carry a small mirror on the ambulance just for this. The moment they see the wound, nearly 100% cooperate.
• explaining the medical risks in clear language. Explaining, that pain will get severe and blood loss will be significant after a short time, when initial shock mechanisms release.
• explain the possible treatment plan and see if there's a problem you can address ("Needles? Your leg is cut off and you still fear needles? That's cool!"). Explain chances of having the leg re-attached or at least saving more of the limb than hours later. Some simply don't know that an ambulance can provide a better ride than a private car ("Think of all the blood on your wife's seats!").
• Explain, that you're not comfortable with the situation. "I'm sure it helps getting you to a hospital now and I really feel bad when not giving you the chance".
• referring to relatives/co-workers and pointing out, that they will have the problem when you leave, including the situation getting worse (more blood, pain, getting unconcious).
• In case of work related accidents I point out the employees duty to get well soon and to be checked through because of possible insurance benefits in later years...Here a clear word by the supervisor/boss often helps.
• arguing his reasons. Often it's "can't pay" or "want family to know", sometimes "don't want friend/coworker to get sued" or even "don't want to get away from my workplace". Others are "You just want me to go to get money" or such crap. If the argument is that they won't want to cause work for us: "We already had a tough ride and now are here..." and/or "We get called out for a lot of crap (maybe insert description of drunks wanting a taxi ride) and you have a real injury here, exactly for this we're there!" - that often works for the tough farmers around here. Or "I have more work documenting when you don't want to go with me, than when I can refer you to a hospital!". Sometimes: "Every call makes our job more secure - if you're not transported, someone may decide sometimes, that there is no ambulance needed to cover this area any more...". And so on.
• In several cases (especially traffic or work accidents) I can treat with police: "Better go with us, or you will go with them". Mostly it's a fake treat, but sometimes work.
• Clear asking if they want to commit suicide. If "yes" it's legally to force him (police!). If "no", well, at least that is ruled out.
• Closing statement (in appropriate wording): "OK, you're fully responsible for your stupidity, please sign here and don't hesitate to call again if you then want to go with me". To the bystanders: "Please call again, if he gets unconcious. Thank you, good bye."

After all, it's the patients right to be so stupid, but it's my responsibility to make certain that he knows how stupid it is.

Dwayne has done a very good job in involving witnesses!

For the side question, what have happened if someone get unconcious after clearly stating not wanting help? Depends. I would be legally safe to start treatment then, assuming he changed his will the moment he passed out. Unless there is a clear written statement in place. Where "clear" and "in place" are often the problem then..."Why did you call us? Next time call your doctor who knows the situation."

[Band Aid]

Sounds like a problem to place in Medical Controls hands. We have radio and cell phone contact with Medical Control and the ED doctor. We are advised by our OMD (Operational Medical Director) to call whenever we feel the refusal is/may be detrimental to the patient. Also as stated above, law enforcement might be able to encourage the individual to go with you.

[island emt]

You do realize this incident happened in the jungles of Papua New Guinea ????

That Dwayne practices as a remote sole source medic at a remote industrial site.

[Band Aid]

You do realize this incident happened in the jungles of Papua New Guinea ????

That Dwayne practices as a remote sole source medic at a remote industrial site.

No I didn't.

[Arctickat]

No I didn't.

That's why netiquette dictates you read the entire thread before commenting. If you had, you would have known that. Perhaps not the specific location, but the gist of him being on the other side of the world.

Edited February 17, 2013 by Arctickat

[paramedicmike]

To be fair, all the OP said was that it was an actual call in a non-American country. He didn't specify in the OP that he was in PNG. We know that simply because we've been here longer.

[Arctickat]

Yes, but reading through the thread provides further information, such as his nearest med control is in Sydney or Singapore, or he is the only medic in the area.

[scubanurse]

Meh, we've all made "netiquette" errors before.