Has this ever happened to you?

[FormerEMSLT297]

I agree with Paramedicmike, if you are going to call a helo,, call asap,, that limits the patients pre-hospital time and makes the most of the "golden hour"

[kpeppermintpatty]

ACE- That puts it in better steps than the MD protocols do, thanks.

Just a note though to those who say transport to closest trauma but no helo- The closest trauma center to my first due is 45-60 min. minimum ground transport, helo is 7-15 minutes. There are also only 2 ER's within 30 min. of here, average ground transport is 20 minutes.

[GreenHat]

Ace wrote: Just FYI, If you ever tried to use your signature line with ANY of the OB's I've worked with or know they would promptly use their speculum with 'wide spread' action on your anus...Most of them have forgotten more in their undergrad years about emergency patient management than you may ever know. Furthermore if you had chosen a non-intensive critical thinking specialty like say..DERM.. I may not say this, But OB?!?!?! WTF? Food for thought before you go saying that to anyone!!

I use that as my signature because my old partner actually had to pull out that line on an OB-GYN who had been treating a patient in an emergency on an airplane and was unwilling to surrender patient care upon landing... it worked then, but you do raise a good point, it was just a funny situation I have been in though.

[SSG G-man]

Ummm...so if you have that many trauma centers that close why do you bother putting a helicopter on standby? There's no need for it. Especially if you decide to wait until you've done an assessment before requesting a fly. If you do that now you have to wait for the helicopter to take off, get to you, land, complete their assessment, load, take off and fly to the hospital. Congratulations! You've just wasted an unacceptable amount of time when you could otherwise have already been en route to, and possibly have arrived at one of those trauma centers before the helicopter would have even landed at the scene.

Your situation isn't limited to Oregon. I've seen it other places, too. In Maryland where this call originally took place (and where I used to work). In Pennsylvania where I currently work. In Virginia and West Virginia, too. I'm not quite sure why people wait so long but for some odd reason they do.

The only time this might be acceptable practice in an urban area is during rush hour where traffic is so bad that even a trauma center three miles away would take you an hour to get to. But there are only a handful of places in the country where that might be a consideration.

Otherwise, thanks for raising an important issue with regards to HEMS.

-be safe.

Mike- I am still in Maryland, and you can not put a helicopter "on hold" or "standby" you either request one or you do not. If you are trying to decide and someone else puts in the request first, you will be getting the second due helicopter. I am lucky I am in an area right between Trooper 2 and Trooper 7. One day we had two serious accidents with in 15 minutes and within a mile of each other. We used two troopers and they brought in the Eagle from the Park Police.

SARGE

[paramedicmike]

Sarge:

Yeah...now that you say that I remember. It's been a while since I've called for a helicopter in MD.

Greenhat:

You still haven't clarified anything. Your two statements still contradict each other and your explanation does nothing to satisfy the complaint.

Patty:

Your description of how long a ground transport versus a flight further supports the argument that you shouldn't wait to call for a Trooper. The longer you wait, the longer the patient has to wait and the longer the whole process of flying the patient becomes. The sooner you call the sooner the Trooper gets there and the sooner the patient in on his/her way to the hospital.

If you think, based on the dispatch description, that you need a helicopter then call for it before you even get on scene. Why? Because they'll be there sooner than if you wait until you've done your assessments. If it turns out that you don't need them then cancel them. Don't worry about calling them out and not needing them. I guarantee they don't mind. They like to fly. And it's even better when they don't have to complete the trip sheet at the end (is the whole state using E-MAIS yet?).

Also, and something I noticed in your initial posting on this topic (forgive me if this was already addressed. I didn't go back and re-read all five pages of responses to see if this came up), please don't document which vehicle is at fault for an accident. Don't document which is the "striking vehicle". If your patient says, "He ran the light and hit me" that's one thing. But if you document which vehicle was the "striking vehicle" and you call winds up in court the lawyers will rip you apart.

Sure, you may be able to put together a pretty good idea of what happened during the accident. But you're not trained to make that kind of assumption in your legally binding PCR regarding what happened during the course of the collision. The lawyers know this and will have show no mercy as they eat you for lunch on the stand.

-be safe.

[SSG G-man]

"If you think, based on the dispatch description, that you need a helicopter then call for it before you even get on scene. Why? Because they'll be there sooner than if you wait until you've done your assessments. If it turns out that you don't need them then cancel them. Don't worry about calling them out and not needing them. I guarantee they don't mind. They like to fly. And it's even better when they don't have to complete the trip sheet at the end (is the whole state using E-MAIS yet?). "

This is very true. One our members flys with the troopers and I think I heard him say they would rather fly someone from a scene that might not have needed to go, than to pick someone up at a hospital that should have been flown to start with.

As far as I know we ar all on EMAIS. I hate it!!

[Ace844]

"Pepper,"

Examples are as follows..

http://www.emtcity.com/phpBB2/viewtopic.php?t=2851

http://www.mass.gov/dph/oems/memos/treatrelease.pdf

http://www.emtcity.com/phpBB2/viewtopic.php?t=3560

http://www.emtcity.com/phpBB2/viewtopic.php?t=2342

http://www.emtcity.com/phpBB2/viewtopic.php?t=1871

http://www.emtcity.com/phpBB2/viewtopic.php?t=2910

http://www.emtcity.com/phpBB2/viewtopic.php?t=1533

http://www.ncbi.nlm.nih.gov/entrez/query.f...p;dopt=Abstract

http://www.jems.com/news/102474/

http://www.mass.gov/dph/oems/admin/ar_5_610.doc

[quote=Consent, Emergency Medicine - Legal Aspects Of Emergency Medicine

Last Updated: April 25, 2005, Author: Ernest L Yeh, MD , Assistant Professor in Emergency Medicine, Department of Emergency Medicine, Temple University Hospital

Coauthor(s): Glenn Freas, MD , Consulting Staff, Department of Emergency Medicine, Virtua Memorial Hospital Burlington County

Ernest L Yeh, MD, is a member of the following medical societies: American Academy of Emergency Medicine, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Editor(s): Lance W Kreplick, MD, MMM , Medical Director, Department of Emergency Medicine, Regional Medical Center - Bayonet Point; Francisco Talavera, PharmD, PhD , Senior Pharmacy Editor, eMedicine; Matthew M Rice, MD, JD , Vice President, Chief Medical Officer, Northwest Emergency Physicians, Assistant Clinical Professor of Medicine, University of Washington at Seattle; Assistant Clinical Professor, Uniformed Services University of Health Sciences; John Halamka, MD , Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Barry Brenner, MD, PhD, FACEP , Professor of Emergency Medicine, Professor of Internal Medicine, and Professor of Anatomy and Neurobiology, Chairman, Department of Emergency Medicine, University of Arkansas for Medical Sciences]

INFORMED CONSENT

The issue of informed consent is of great concern in emergency care. Several ethical and legal principles define the parameters of informed consent. The concept of autonomy provides the basis for informed consent as well as the basis for refusal of medical treatment. Although autonomy is an ethical concept, it also is one of the foundations of various legal principles including self-governance, liberty, rights, privacy, and individual choice.

US Supreme Court Justice Benjamin Cardozo stated, "Every human being of adult years and sound mind has a right to determine what shall be done with his own body."

The physician-patient relationship is a dynamic interaction. Traditionally, physicians paternalistically administered those treatments they considered best for patients. Historically, a patient could consent to treatment simply by lack of objections. The current interpretation of consent has evolved to require a more active role on behalf of the patient. The physician must disclose risks, benefits, and alternative treatments to the patient. Informed consent requires a competent patient who makes a voluntary decision based upon adequate information.

For excellent patient education resources, visit eMedicine's Public Health Center and Senior Health Center . Also, see eMedicine's patient education articles Informed Consent, Patient Rights, and End-of-Life Decision Making .

PATIENT COMPETENCY AND ISSUES INVOLVING MINORS

To obtain consent, the patient must be clinically and legally competent. In most states, the legal age of consent for medical treatment is 18 years. Parents or legal guardians normally are required to consent for the medical treatment of minors, although a few exceptions exist as follows:

The Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to provide an adequate medical screening examination to anyone (including minors) who presents to the ED, even if appropriate consent cannot be obtained. If no immediately life-threatening condition is identified, institute procedures to obtain consent for treatment.

In many states, marriage or pregnancy often confers an emancipated status to minors, who then can consent to procedures and treatments.

In the interest of a greater societal good, various conditions exist (depending upon the state) for which minors can consent to treatment. These conditions include treatment for (1) sexually transmitted diseases, (2) alcohol or drug abuse, (3) domestic or sexual abuse, and (4) mental health issues.

Minor parents of children also can consent to treatment for their children and themselves.

Additionally, mature minors (ie, close to age of maturity) can consent, at times, to less invasive or less risky procedures if the physician feels the patient understands the concepts of consent.

Clinical competency can be defined as the ability to comprehend and rationally act upon information provided by a healthcare professional. Intoxication and active psychosis affect an individual's ability to give adequate consent. Carefully examine the patient's mental status and reasoning ability when trying to obtain consent. Furthermore, common law or other statutes may govern which patients can consent legally.

In addition to determining the patient's competency to consent to medical treatment, the physician must impart the appropriate information to obtain consent. In some states, the standard of disclosure is defined as what a reasonable physician in a similar situation would disclose; other states require disclosure of the risks and alternative treatment options that a reasonable patient would want to know before consenting to a proposed therapy. In some circumstances, physicians may invoke therapeutic privilege and do not have to disclose extremely rare risks or complications that, if disclosed to the patient, may unreasonably prejudice the patient's decision.

TYPES OF CONSENT

Distinctions are made among various types of consent.

General consent

When patients present to the ED, they typically sign a general consent during the registration process. General consent indicates that the patients are willing to undergo basic evaluation and treatment. Controversy exists regarding the definition of basic treatment. Few argue that taking vital signs or performing a routine physical examination requires the physician to obtain further consent from the patient.

Nonemergent specific consent

Obtain a more nonemergent specific consent for procedures and treatments that may be more invasive (eg, chest tube placement), have more risks (eg, conscious sedation vs general anesthesia), or may be considered experimental.

Ideally, physician-patient discussion should be witnessed and written documentation of consent obtained. Discussion should include the following:

Specifics of the procedure (ie, why it is being performed, how it is performed)

Risks and benefits

Any alternative treatments

Risks of refusing the procedure

Emergency consent

In an emergency, attempt to obtain informed consent from the patient or from an appropriate surrogate decision maker. In certain situations, emergency consent is implied. In these instances, normal consent standards are not followed because immediate treatment may be required even before an opportunity to obtain consent is available. The assumption is made that the average, reasonable, competent patient would agree to standard treatment in an emergency if able to consent. An example of such a situation is a patient who suffered a pneumothorax and, as a result of decompensating vital signs, is unresponsive and unable to give consent. In the best interest of the patient, the physician should proceed with a tube thoracostomy rather than try to obtain consent.

Caveat to consent issues

Emergency or implied consent cannot always be applied simply because a patient presents to the ED. If a patient's condition is not immediately life threatening, consent must be obtained from the patient or the appropriate surrogate. For example, a patient who presents to the ED with an acute-onset headache and requires a workup for a possible subarachnoid hemorrhage does not automatically consent to a lumbar puncture simply because she or he is in the ED. If the patient is of sound mind and judgment and refuses to consent to the procedure, the physician cannot apply emergency consent and may not proceed.

REFUSAL OF TREATMENT

The US Supreme Court has recognized that a "person has a constitutionally protected liberty interest in refusing unwanted medical treatment" even if refusal could result in death. The prudent physician tries to explore the reasons for refusing therapy. If the patient continues to decline treatment, document this discussion and refusal. This can be done on a "discharge against medical advice" form.

Although courts protect a patient's rights to refuse care, "preservation of life, prevention of suicide, maintenance of the ethical integrity of the medical profession, and protection of innocent third parties" also may be considered when evaluating a patient's wish to refuse treatment. Each case must be examined individually.

In discussions concerning the refusal of appropriate treatment, inform the patient of possible adverse outcomes resulting from inadequate treatment. Provide information regarding available treatment even to patients with terminal diseases who have advanced directives. Patients frequently reconsider treatment when informed of the possibility of disability or death. Additionally, patients often refuse to consent simply because they do not understand the proposed therapy completely. Encourage patients who refuse care to return should they change their minds.

If a parent's refusal of treatment seriously jeopardizes a child's well-being, physicians may consider taking temporary protective custody under child abuse laws, which vary from state to state. In general, parents cannot refuse life-saving therapy on religious or other grounds. Courts previously have decided in favor of the physician treating the minor. Time permitting, whenever needed medical care for a minor is refused, the responsible provider and institution should seek assistance from appropriate court authorities and ethics committees.

CONCLUSION

In providing medical care, the universal goal is to act in the best interest of the patient. A patient's best interest may be served by providing leading-edge medical treatment, or it may be served simply by honoring a patient's refusal of care. This goal is based on the principle of autonomy, which allows patients to decide what is best for them. Although complicated issues can arise when physicians and patients disagree, the best policy is to provide adequate information to the patient, allow time for ample discussion, and document the medical record meticulously. BIBLIOGRAPHY Section 7 of 7 Prev Top

Author Information Informed Consent Patient Competency And Issues Involving Minors Types Of Consent Refusal Of Treatment Conclusion Bibliography

Cruzon v Director, Missouri Dept of Health : 497 US 278 (1990).

Natanson v Kline : 354 P2d 670 (Kan 1960).

O'Brien v Cunard Steamship Company Limited : 154 Mass 272, NE 266 (1891).

Schoendorff v Society of New York Hospital : 211 NY, 105 NE 92, 93 (1914).

Scott v Bradford : 606 P2d 554, 558 (Okla 1979).

State v Perricone : NJ Rep 463, Vol 37.

Beauchamp TL, Childress JF: Principles of biomedical ethics. New York: Oxford UP; 1989:68.

Garwin M: The duty to care--the right to refuse. Changing roles of patients and physicians in end-of-life decision making. J Leg Med 1998 Mar; 19(1): 99-125 [Medline] .

Nora LM, Benvenuti RJ 3rd: Medicolegal aspects of informed consent. Neurol Clin 1998 Feb; 16(1): 207-16 [Medline] .

Siegel DM: Consent and refusal of treatment. Emerg Med Clin North Am 1993 Nov; 11(4): 833-40 [Medline]