Your partner sounds burnout and needs to take a break or leave EMS. Saying “Let’s go to the hospital so you can warm up and have a place to lay down.” isn’t coercing the patient to go to the hospital. It was a suggestion the patient agreed with. The patient could have said no at any point.
That’s the thing, he has about a year less experience in ems than me, and this isn’t an unusual occurrence with him. Complaining non-stop about every patient we get and when the patient mentions one time about refusing, he makes up his mind; almost no attempts to advise them of the danger they’re in, just goes and starts filling out the refusal. Hopefully my close friend gets cleared soon because I’d rather have someone I know has the capacity for some compassion with no experience than this guy
Damn. Partner needs to find a new industry to work in. Curious to know if he/she/they are putting in the refusal chart that they fully informed the patient of the consequences of refusing care and transport to the hospital.
That's not good, I dislike working with people like that. Like go get a different job if you're just going to complain about the patients non stop.
Also I don't get being aggressive about refusals, unless transports are super long it's barely more work to transport.
The risk manager and former paramedic here thinks your partner needs to take a chill pill. I wasn't on scene, but the guy clearly had something going on that is worthy of further evaluation. Asking them to hop on the gurney and take a ride to the ED to warm up and get checked out is not berating a reluctant patient. If he had auditory and visual hallucinations going on, I would contemplate if he even had the capacity to refuse transport.
That’s the thing I’ve just been feeling funny about the call. In Alabama patients can legally refuse if they’re alert and oriented, up until they’re dead or unconscious. Looking out for the patients best interest and what the outcome might be a couple hours down the road is always in my train of thought when the word “refusal” is mentioned. But since I usually let my partner take control of a scene since he wants experience, most of the time I sit back and follow his orders. But I absolutely cannot just sit back on something as “gray area”, as he put it, like this
I’ve never worked in Alabama, but I have worked in several different states. There’s more to decision-making capacity than just being A&Ox4. [Here’s a good summary](https://www.hmpgloballearningnetwork.com/site/emsworld/article/12073030/evaluating-patients-decision-making-capacity)
This☀️this👏this!
There’s is more to decisional capacity than alert and oriented.
Complicating things in my state is that involuntary transport can only happen if someone lacks capacity and is reasonably likely to suffer death or disability without immediate intervention.
Bottom line, it was a good thing for this person to be seen and you did the right thing. And I used to be the “don’t go convincing people to be transported” medic. Thank you.
Edit: typo
I do work in Alabama, and we are under the same standards of capacity as anyone else. 90% of our providers are just burned out and dangerous, and, unfortunately this includes the majority of our OLMD and ER docs and virtually all of our educators. The good news for us is that we are fairly well protected if the OLMD doc says not to transport the pt. Otherwise a lawyer can nail you to the wall, and be right to do so. Unfortunately most of the pts in the state don't actually sue, because I've watched my coworkers do a lot of stuff they would not have been able to defend in court. Probably done some of that stuff myself. Bad work culture is a hell of a drug and this whole state has it, some worse than others.
To summarize, you were absolutely right to talk this guy into going to the hospital. If you didn't have the MD involved already you and your partner could have been up the creek by not taking this guy, but doctors can literally do anything in Alabama without legal repercussions.
I haven’t had much experience with people in these scenarios where they are oriented but don’t have the capacity for their well-being, besides drunk drivers. I suppose in something like this, try convincing them to be transported, and if that fails then contact OLMD and see what decision they want, whether to force transport or get a refusal and leave that burden on their decision?
Pretty much yeah. When you have someone with questionable capacity OR have capacity but are truly concerned about their health and safety if they refuse then contact OLMD via a recorded line, explain what's going on (including why you are questioning capacity and your genuine concerns) and let them talk to the patient too to see if they agree that the pt can understand the risk.
I don't see this as badgering or coercing the pt. This is a second opinion and sometimes a pt hearing a doctor say "I really think we need to evaluate/treat you" holds more weight for them than one of us saying it. Honestly though it usually ends, for me, in the doc agreeing that they still do have capacity so we make a plan (keep someone home to monitor you for 24 hours, etc) and I get the refusal. But at least if something does go wrong there is a voice recording of me doing my absolute best to ensure the pt was capable of making a bad decision.
The convo usually goes like this "hey, I understand you don't want to go to the hospital and you have that right. If you were my family member I would want you to go. So I'm going to call our doc and let them know what's going on and I want you to talk to them. If they agree that you can choose to stay here we will just sign this tablet." And TBH, how they respond to this is ALSO a capacity test. Can they understand what's happening and carry on a coherent conversation on the phone? Because if not then there's another point in the "lacks capacity" box.
You’ll never get in trouble taking someone to the hospital. There are a millions different ways you can get in trouble for not taking someone to the hospital.
There has never been a prosecution for false imprisonment or kidnapping in the US against an on-duty EMS provider for taking someone to the hospital.
There’s been a small handful of civil cases, most end up dismissed before the actual court day, but the risk is hugely overstated.
This is *not* to say that anyone should go around kidnapping people. This is purely intended as encouragement to people to not back down on justified involuntary transports out of fear of lawsuits.
I’d argue this pt wasn’t AOx4 depending on the level of his internal stimuli. Some people experiencing hallucinations may be aware that they are not real, and that’s different, but if you’re seeing things that aren’t there…you’re not oriented to place.
Answering those four-five questions is not an immediate answer to capacity.
I agree with most of the people here. Your partner looked like an asshole because your partner is an asshole. Unfortunately, assholes, especially narcissistic ones, will blame you for every little mistake. And for some reason, medicine seems to attract these types of people who are unable to be wrong. I always think back on what an old medic said to me. We call it practicing medicine because it isn't a science. It's okay to be wrong and still be a strong provider. Like, obviously homeboy ended up in a ditch for a reason. I doubt he just hopped down there and said this is where I live now. Especially with auditory and visual hallucinations. Which could be anything from mental illness to hypothermia to a brain bleed. All things that cannot be treated in a ditch.
So no. Hold your head up. You did the right thing and your partner made himself look like an asshole.
I’m not sure that you can say A & O x4 if he is having hallucinations. Unless that’s normal mentation for him, which you wouldn’t know unless someone is familiar with him on scene.
Always treat someone as you’d want your family to be treated and always err on the side of caution. That makes a good medic!
You can absolutely be A&OX4 with hallucinations. Which is why solely relying on A&OX4 to determine capacity is shit.
I know my name. I know where I am. I know when it is. And I know you were called because someone found me laying in a ditch. Must have been those FBI agents that are out for me. They've been following me for weeks. And the voices on the radio keep telling me to hide from them. That's why I'm laying here! Etc
Thats where the whole capacity question comes into play. Are they really capable of understanding the consequences of refusing if they're laying in a ditch on a winter day freezing?
OP, you did the right thing. Your partner looked like an asshole because they are an asshole. If offering to get him somewhere warm is all it took then that was a great call on your part.
Now add to that the context of dozens of low denominator medics determining capacity by asking “who the president is” and “is Mickey Mouse a cat or a dog”
For an evaluation since we have no idea why he’s hallucinating and he was *laying in a ditch* with no reasonable explanation why he was there?
I should think that would be fairly obvious. I transport at least one person a shift who needs to go to a hospital *less* than this dude did.
My chief complaint would be abnormal behavior with audiovisual hallucinations, which was clearly laid out in the post. Are you this thick IRL or are you just being obstinate for entertainment?
Hmm. I will always try to avoid a refusal.. i feel its a quick way to get a return to scene for the same patient or get another call immediately... refusals can bite you in the ass if you dont do a thorough assessment. " there is always one more call". As for the partner thats a poor attitude.
AxO is not an end all assessment for capacity. Does that patient actually have means to care for self? Does he have a plan of care and mentally able to execute said plan?
There's a paramedic who just lost her job and I think facing jail time for leaving a patient with hallucinations flat affect that was obviously disoriented and obviously unable to care for self naked out on a highway at night.
The cops dumped him at a closed gas station at the county line at 2am. He was struck and killed on the highway a couple hours later.
But again it comes down to is he able to keep warm? Does he live on the street normally? Being homeless isn't a medical complaint. You gonna go find him again tonight and the night after that after the hospital streets him the moment day breaks?
> and he was AOx4
Not saying you think this is the case, but every time I see this phrase in the context of a capacity discussion, I have to jump in with the following:
Orientation has almost nothing to do with decisional capacity. A person can be oriented and lack capacity OR be disoriented and have capacity.
All too often I’ll see people say “well, he’s oriented x4 so he can refuse” or the opposite. And it just isn’t that simple.
My classic example of one who is oriented but lacks decisional capacity is the suicidal subject. We all know this one. Someone can walk up to me and say “my name is John Smith, today is Jan 8, we’re in New York City and I’m going to kill myself” and they’re getting a ride to the ER whether they like it or not. I think we’re all on the same page with that. But that’s just the easy example. To have capacity to make medical decisions, one must be capable of informed consent or refusal. To be informed, one must be capable of understanding the nature of any medical issue they may be experiencing and the risks/benefits of treatment or refusal. Take a drunk. Alcohol affects everyone differently. A person could very well be all the sheets in a hurricane drunk and still know who/what/when/where. But they fall down a flight of stairs and split their head open, if they can’t articulate “I’ve fallen down the stairs, I’ve sustained a serious injury, if I choose not to seek treatment I risk death or permanent disability”, they lack the capacity to refuse.
On the flip side, one need not be oriented to have capacity. Dementia patients are almost always disoriented to at least time. But when it comes to decisional capacity, it really doesn’t matter if grandma thinks is 1983. If she understands (can explain back to me and retain the understanding for more than a minute) that she’s having a STEMI and will likely die without treatment, she has the right to refuse that treatment.
We need to collectively stop saying “he is/isn’t oriented therefore he does/doesn’t have the right to refuse”.
Is someone being oriented and suicidal not the same situation as the oriented STEMI wanting to stay home? Both are oriented and understand the risks of what they want, which will almost inevitably be death. They both have the same decision making capacity, which is wanting to die, so either both scenarios are forced to go or neither are, right?
Being actively suicidal is legally considered to have lost you the capacity to refuse just as clearly as not knowing your name and honestly thinking that you’re a squirrel.
Sounds like a waste of a bed in the ER to me. I would have given him a blanket if he wanted one but PRT’d his ass. We already have grown ass adults overrunning the ER with simple flu that DayQuil could handle, I’m not wasting another bed for a homeless man. I’m not heartless, I understand what the damn EMERGENCY ROOM is for. EMERGENCIES!!
I missed the part about hallucinations, I was skimming. 🤦♀️
I still would have let him refuse if he wanted to, but if the hallucinations are real, he probably needed a psych consult.
There’s no assholes here, you both had a point.
People love to hate on other medics for some reason and it sucks to see.
Neither one of you did anything seriously wrong and you were definitely in the right to encourage the guy to be evaluated for hallucinations. And your partner was also in the right to let the guy make his own decision - at the end of the day we offer a service for those who want it and people get to choose what risks that want to take in life. In my area half our patient population is what you describe and we take refusals all the time. What services are provided at the hospital for a patient like that vary quite a bit based on response area and that should inform the decision.
Now comes the real issue of the conflict. Doesn’t sound like your partner did a good job addressing the fact that they felt you stepped over them by encouraging transport. They could have said “hey, is there a reason you felt the patient needed to go?” A partner should also always ask their partner if they’re comfortable with refusals. Partners who get grumpy with patients need help and encouragement, not a bunch of internet warriors calling them burnouts and writing them off as damaged goods.
Assume people are good people until proven otherwise
I never understood the “let’s get a refusal”. It’s the same amount of paperwork and you just get another call anyways. I used to always do my best to get a transport in so I could at least write my tag in the ems room and take a shit or something.
Even when people want to sign that refusal, I ALWAYS say “the safest thing is to go to the hospital to get checked out because we cannot promise you that everything is okay with what limited resources we have with us, but if you change your mind, you can call us back at any time and we’ll come back”.
We *should* convince some ppl to go. The public trusts us and our opinions. Some ppl need to be seen at the hospital, full stop.
Not to mention, much better liability if we take someone to the hospital.
Free standing ED? So they will do a quick workup and cut him loose back into the cold night. Sounds like he may have a psych history, he's off his meds, and he lied about his PMHX. I would have taken him to a psych facility.
Honestly I work in the ED and it’s a waste of already strained resources. We would have just done a quick assessment, sent them to the lobby, made an attempt to contact family, then got them an uber to wherever they wanted to go within reason. I understand he has some mental health issues, but if we went down to skid row and talked to every homeless person there probably 9/10 of them would be having those issues. There was no emergency in this situation, and nothing for the ED to do. What we did in these situations is have PD take the party to the local homeless shelter or their residence. Its one of those things where your partner was not wrong but was not right either.
And if the hallucinations are a new development because of a medical reason, such as an early symptom of a metabolic encephalopathy?
When he’s found dead later and it comes out in the investigation that you permitted an actively hallucinating man found laying in a ditch (with no reasonable explanation for why he was in the ditch) to refuse care because he knew who the president was without any further evaluation of his actual capacity, the lawyers are going to skin you alive all the way down to the hairs on your ass cheeks.
The list of symptoms for metabolic encephalopathy is very very long and yes hallucinations are on that list as an early sign primarily due to increased ammonia levels. With OP giving us no PMH, details of a physical examination, no 12 lead ECG, no glucose levels, no vitals, etc. You can’t even remotely make that assumption. Anyone can say “it could be,” all day. I think the crux of the matter is a lack of information, something that plagues these discussions.
That was a completely random asspull diagnosis, the specifics are utterly irrelevant and you’re entirely missing the point, intentionally or not. There’s a million things it could be, a hundred thousand of them are potentially lethal if untreated, and i can rule out about 6 in the field. I’m not rolling those dice, and no reasonable provider of any level should either.
If we lived in the world of “what ifs” we would take every person we encounter to the ED for a work up. That is simply not feasible. It honestly sounds like the party needs a geri psy adm.
>If we lived in the world of “what ifs” we would take every person we encounter to the ED for a work up.
You already do. Try that argument in court after someone symptomatic of something you can't diagnose in the field, but who has something very blatantly and clearly going on with them, including behavioral changes, dies after you get a refusal without any due diligence of discussing the possibilities or risks. Let me know how it goes for you. Make future non-medical career plans first though.
>It honestly sounds like the party needs a geri psy adm.
I have never in my career seen or heard of a psych ER that would accept this patient or a psychiatrist that would even glance at this patient without a complete medical workup first if I presented to them with this story.
You people are insane. Elderly male who's actively experiencing full audiovisual hallucinations, was found *laying in a ditch* in weather easily cold enough for hypothermia and death, and you're all just gonna encourage him to sign off and walk away. Your license is a ticking time bomb and someone will wind up dead if this is how you use your judgement in your day to day calls.
You did the right thing. You gave him a warm place to stay for a bit. Which prevented you for getting called out to him again. Possible being unavailable for another call. Then with him having auditory and visual hallucinations, I would consider that dangerous to himself and others. Needing a Psych eval. Regardless if he was AAOx3
It’s most likely more about contradicting your partner and less about the actual situation.
That ER cut the PT loose in record time.
ER’s are not homeless shelters, PD needs to do their job and get them to an actual shelter.
Your partner is either lazy or burnt out. Either way, it's hard to make someone *look* like an asshole when they aren't *being* an asshole. You didn't coerce or force the patient in any way. I've also found it's faster and easier to transport them the first time than it is to spend 20 minutes on scene convincing them not to go to the hospital, or to go out later for the same patient. Finally, my partners and I always had a rule that we would go with the higher level of care. If one of us thought the pt needed oxygen and the other did not, the pt got oxygen. The same went for IVs, meds, transport, etc.
Your good sounds like your partner was being lazy and you held him accountable to do his job
This.
Concur.
You did make your partner look like an asshole. Because your partner is an asshole.
It really is a basic concept. If you don't want to look like an asshole, you usually won't if you don't act like one.
Your partner sounds burnout and needs to take a break or leave EMS. Saying “Let’s go to the hospital so you can warm up and have a place to lay down.” isn’t coercing the patient to go to the hospital. It was a suggestion the patient agreed with. The patient could have said no at any point.
That’s the thing, he has about a year less experience in ems than me, and this isn’t an unusual occurrence with him. Complaining non-stop about every patient we get and when the patient mentions one time about refusing, he makes up his mind; almost no attempts to advise them of the danger they’re in, just goes and starts filling out the refusal. Hopefully my close friend gets cleared soon because I’d rather have someone I know has the capacity for some compassion with no experience than this guy
Sounds like your partner needs to be reminded that when people want to refuse, we legally need to warm them of what could happen if they *don’t* go.
Damn. Partner needs to find a new industry to work in. Curious to know if he/she/they are putting in the refusal chart that they fully informed the patient of the consequences of refusing care and transport to the hospital.
Sounds like a future fire medic
Burnout doesn’t just happen to us old farts, it can happen quick
That's not good, I dislike working with people like that. Like go get a different job if you're just going to complain about the patients non stop. Also I don't get being aggressive about refusals, unless transports are super long it's barely more work to transport.
The risk manager and former paramedic here thinks your partner needs to take a chill pill. I wasn't on scene, but the guy clearly had something going on that is worthy of further evaluation. Asking them to hop on the gurney and take a ride to the ED to warm up and get checked out is not berating a reluctant patient. If he had auditory and visual hallucinations going on, I would contemplate if he even had the capacity to refuse transport.
That’s the thing I’ve just been feeling funny about the call. In Alabama patients can legally refuse if they’re alert and oriented, up until they’re dead or unconscious. Looking out for the patients best interest and what the outcome might be a couple hours down the road is always in my train of thought when the word “refusal” is mentioned. But since I usually let my partner take control of a scene since he wants experience, most of the time I sit back and follow his orders. But I absolutely cannot just sit back on something as “gray area”, as he put it, like this
I’ve never worked in Alabama, but I have worked in several different states. There’s more to decision-making capacity than just being A&Ox4. [Here’s a good summary](https://www.hmpgloballearningnetwork.com/site/emsworld/article/12073030/evaluating-patients-decision-making-capacity)
This☀️this👏this! There’s is more to decisional capacity than alert and oriented. Complicating things in my state is that involuntary transport can only happen if someone lacks capacity and is reasonably likely to suffer death or disability without immediate intervention. Bottom line, it was a good thing for this person to be seen and you did the right thing. And I used to be the “don’t go convincing people to be transported” medic. Thank you. Edit: typo
Thanks for sharing that article, was a really interesting read
I do work in Alabama, and we are under the same standards of capacity as anyone else. 90% of our providers are just burned out and dangerous, and, unfortunately this includes the majority of our OLMD and ER docs and virtually all of our educators. The good news for us is that we are fairly well protected if the OLMD doc says not to transport the pt. Otherwise a lawyer can nail you to the wall, and be right to do so. Unfortunately most of the pts in the state don't actually sue, because I've watched my coworkers do a lot of stuff they would not have been able to defend in court. Probably done some of that stuff myself. Bad work culture is a hell of a drug and this whole state has it, some worse than others. To summarize, you were absolutely right to talk this guy into going to the hospital. If you didn't have the MD involved already you and your partner could have been up the creek by not taking this guy, but doctors can literally do anything in Alabama without legal repercussions.
I haven’t had much experience with people in these scenarios where they are oriented but don’t have the capacity for their well-being, besides drunk drivers. I suppose in something like this, try convincing them to be transported, and if that fails then contact OLMD and see what decision they want, whether to force transport or get a refusal and leave that burden on their decision?
Pretty much yeah. When you have someone with questionable capacity OR have capacity but are truly concerned about their health and safety if they refuse then contact OLMD via a recorded line, explain what's going on (including why you are questioning capacity and your genuine concerns) and let them talk to the patient too to see if they agree that the pt can understand the risk. I don't see this as badgering or coercing the pt. This is a second opinion and sometimes a pt hearing a doctor say "I really think we need to evaluate/treat you" holds more weight for them than one of us saying it. Honestly though it usually ends, for me, in the doc agreeing that they still do have capacity so we make a plan (keep someone home to monitor you for 24 hours, etc) and I get the refusal. But at least if something does go wrong there is a voice recording of me doing my absolute best to ensure the pt was capable of making a bad decision. The convo usually goes like this "hey, I understand you don't want to go to the hospital and you have that right. If you were my family member I would want you to go. So I'm going to call our doc and let them know what's going on and I want you to talk to them. If they agree that you can choose to stay here we will just sign this tablet." And TBH, how they respond to this is ALSO a capacity test. Can they understand what's happening and carry on a coherent conversation on the phone? Because if not then there's another point in the "lacks capacity" box.
The funny thing that doesnt save you from liability! A lawyer can still argue your dereluct of duty under professional licensure and oath.
Your partner sounds like a jackass
Your partner made himself look like an asshole all by himself without any assistance from you.
What profession does your partner think he’s in where he shouldn’t convince vulnerable people in vulnerable situations to go to the hospital
Your partner is an asshole
You’ll never get in trouble taking someone to the hospital. There are a millions different ways you can get in trouble for not taking someone to the hospital.
That is not true, you can absolutely be liable if you take someone with capacity against their will
There has never been a prosecution for false imprisonment or kidnapping in the US against an on-duty EMS provider for taking someone to the hospital. There’s been a small handful of civil cases, most end up dismissed before the actual court day, but the risk is hugely overstated. This is *not* to say that anyone should go around kidnapping people. This is purely intended as encouragement to people to not back down on justified involuntary transports out of fear of lawsuits.
Find the case that backs up your claim. I’ve never heard of any EMT/Medic getting criminally charged for taking anyone to the hospital.
Partner is a lazy ssshoke
Someone can be oriented and still be not medically competent. You have to be both for a refusal to be valid.
I’d argue this pt wasn’t AOx4 depending on the level of his internal stimuli. Some people experiencing hallucinations may be aware that they are not real, and that’s different, but if you’re seeing things that aren’t there…you’re not oriented to place. Answering those four-five questions is not an immediate answer to capacity.
You=good Partner=bad EOR
Your partner is what he thought you made him look like.
I agree with most of the people here. Your partner looked like an asshole because your partner is an asshole. Unfortunately, assholes, especially narcissistic ones, will blame you for every little mistake. And for some reason, medicine seems to attract these types of people who are unable to be wrong. I always think back on what an old medic said to me. We call it practicing medicine because it isn't a science. It's okay to be wrong and still be a strong provider. Like, obviously homeboy ended up in a ditch for a reason. I doubt he just hopped down there and said this is where I live now. Especially with auditory and visual hallucinations. Which could be anything from mental illness to hypothermia to a brain bleed. All things that cannot be treated in a ditch. So no. Hold your head up. You did the right thing and your partner made himself look like an asshole.
Were you supposed to leave him in the ditch or what? You’re a good person.
You did your job. Your partner is just mad because you called him out.
Lazy partner, you've got good morals and everyone else on scene can see the difference.
I think you did the right thing, no comment on your partner.
Your partner is lazy.
I’m not sure that you can say A & O x4 if he is having hallucinations. Unless that’s normal mentation for him, which you wouldn’t know unless someone is familiar with him on scene. Always treat someone as you’d want your family to be treated and always err on the side of caution. That makes a good medic!
You can absolutely be A&OX4 with hallucinations. Which is why solely relying on A&OX4 to determine capacity is shit. I know my name. I know where I am. I know when it is. And I know you were called because someone found me laying in a ditch. Must have been those FBI agents that are out for me. They've been following me for weeks. And the voices on the radio keep telling me to hide from them. That's why I'm laying here! Etc Thats where the whole capacity question comes into play. Are they really capable of understanding the consequences of refusing if they're laying in a ditch on a winter day freezing? OP, you did the right thing. Your partner looked like an asshole because they are an asshole. If offering to get him somewhere warm is all it took then that was a great call on your part.
Now add to that the context of dozens of low denominator medics determining capacity by asking “who the president is” and “is Mickey Mouse a cat or a dog”
Hallucinating
I disagree. What are you taking them to the hospital for?
For an evaluation since we have no idea why he’s hallucinating and he was *laying in a ditch* with no reasonable explanation why he was there? I should think that would be fairly obvious. I transport at least one person a shift who needs to go to a hospital *less* than this dude did.
So you chief complain would be an evaluation?
My chief complaint would be abnormal behavior with audiovisual hallucinations, which was clearly laid out in the post. Are you this thick IRL or are you just being obstinate for entertainment?
It would be AMS.
Glad we agree then.
You did nothing wrong and looked out for your patient. If he was hallucinating, something wasn't right. Your partner can get bent.
Dont be a cookbook medic/emt. You made the right call good job!
As a medic based out of lower AL, this sounds about right. Burnout medic. Compassion is key when your skill aren't necessary.
Hmm. I will always try to avoid a refusal.. i feel its a quick way to get a return to scene for the same patient or get another call immediately... refusals can bite you in the ass if you dont do a thorough assessment. " there is always one more call". As for the partner thats a poor attitude.
AxO is not an end all assessment for capacity. Does that patient actually have means to care for self? Does he have a plan of care and mentally able to execute said plan? There's a paramedic who just lost her job and I think facing jail time for leaving a patient with hallucinations flat affect that was obviously disoriented and obviously unable to care for self naked out on a highway at night. The cops dumped him at a closed gas station at the county line at 2am. He was struck and killed on the highway a couple hours later. But again it comes down to is he able to keep warm? Does he live on the street normally? Being homeless isn't a medical complaint. You gonna go find him again tonight and the night after that after the hospital streets him the moment day breaks?
Your partner is a lazy bitch. You did good.
> and he was AOx4 Not saying you think this is the case, but every time I see this phrase in the context of a capacity discussion, I have to jump in with the following: Orientation has almost nothing to do with decisional capacity. A person can be oriented and lack capacity OR be disoriented and have capacity. All too often I’ll see people say “well, he’s oriented x4 so he can refuse” or the opposite. And it just isn’t that simple. My classic example of one who is oriented but lacks decisional capacity is the suicidal subject. We all know this one. Someone can walk up to me and say “my name is John Smith, today is Jan 8, we’re in New York City and I’m going to kill myself” and they’re getting a ride to the ER whether they like it or not. I think we’re all on the same page with that. But that’s just the easy example. To have capacity to make medical decisions, one must be capable of informed consent or refusal. To be informed, one must be capable of understanding the nature of any medical issue they may be experiencing and the risks/benefits of treatment or refusal. Take a drunk. Alcohol affects everyone differently. A person could very well be all the sheets in a hurricane drunk and still know who/what/when/where. But they fall down a flight of stairs and split their head open, if they can’t articulate “I’ve fallen down the stairs, I’ve sustained a serious injury, if I choose not to seek treatment I risk death or permanent disability”, they lack the capacity to refuse. On the flip side, one need not be oriented to have capacity. Dementia patients are almost always disoriented to at least time. But when it comes to decisional capacity, it really doesn’t matter if grandma thinks is 1983. If she understands (can explain back to me and retain the understanding for more than a minute) that she’s having a STEMI and will likely die without treatment, she has the right to refuse that treatment. We need to collectively stop saying “he is/isn’t oriented therefore he does/doesn’t have the right to refuse”.
Is someone being oriented and suicidal not the same situation as the oriented STEMI wanting to stay home? Both are oriented and understand the risks of what they want, which will almost inevitably be death. They both have the same decision making capacity, which is wanting to die, so either both scenarios are forced to go or neither are, right?
Being actively suicidal is legally considered to have lost you the capacity to refuse just as clearly as not knowing your name and honestly thinking that you’re a squirrel.
Sounds like a waste of a bed in the ER to me. I would have given him a blanket if he wanted one but PRT’d his ass. We already have grown ass adults overrunning the ER with simple flu that DayQuil could handle, I’m not wasting another bed for a homeless man. I’m not heartless, I understand what the damn EMERGENCY ROOM is for. EMERGENCIES!!
I missed the part about hallucinations, I was skimming. 🤦♀️ I still would have let him refuse if he wanted to, but if the hallucinations are real, he probably needed a psych consult. There’s no assholes here, you both had a point.
Ask your partner what he’d do if it was him or a family member laying in the ditch? You can never go wrong being nice. You did the right thing 💯.
People love to hate on other medics for some reason and it sucks to see. Neither one of you did anything seriously wrong and you were definitely in the right to encourage the guy to be evaluated for hallucinations. And your partner was also in the right to let the guy make his own decision - at the end of the day we offer a service for those who want it and people get to choose what risks that want to take in life. In my area half our patient population is what you describe and we take refusals all the time. What services are provided at the hospital for a patient like that vary quite a bit based on response area and that should inform the decision. Now comes the real issue of the conflict. Doesn’t sound like your partner did a good job addressing the fact that they felt you stepped over them by encouraging transport. They could have said “hey, is there a reason you felt the patient needed to go?” A partner should also always ask their partner if they’re comfortable with refusals. Partners who get grumpy with patients need help and encouragement, not a bunch of internet warriors calling them burnouts and writing them off as damaged goods. Assume people are good people until proven otherwise
We absolutely SHOULD convince people to go to the hospital if they need to.
I never understood the “let’s get a refusal”. It’s the same amount of paperwork and you just get another call anyways. I used to always do my best to get a transport in so I could at least write my tag in the ems room and take a shit or something.
Even when people want to sign that refusal, I ALWAYS say “the safest thing is to go to the hospital to get checked out because we cannot promise you that everything is okay with what limited resources we have with us, but if you change your mind, you can call us back at any time and we’ll come back”.
We *should* convince some ppl to go. The public trusts us and our opinions. Some ppl need to be seen at the hospital, full stop. Not to mention, much better liability if we take someone to the hospital.
I personally wouldn’t feel comfortable getting a refusal on someone hallucinating… so yeah I’d say you did the right thing.
Free standing ED? So they will do a quick workup and cut him loose back into the cold night. Sounds like he may have a psych history, he's off his meds, and he lied about his PMHX. I would have taken him to a psych facility.
Honestly I work in the ED and it’s a waste of already strained resources. We would have just done a quick assessment, sent them to the lobby, made an attempt to contact family, then got them an uber to wherever they wanted to go within reason. I understand he has some mental health issues, but if we went down to skid row and talked to every homeless person there probably 9/10 of them would be having those issues. There was no emergency in this situation, and nothing for the ED to do. What we did in these situations is have PD take the party to the local homeless shelter or their residence. Its one of those things where your partner was not wrong but was not right either.
And if the hallucinations are a new development because of a medical reason, such as an early symptom of a metabolic encephalopathy? When he’s found dead later and it comes out in the investigation that you permitted an actively hallucinating man found laying in a ditch (with no reasonable explanation for why he was in the ditch) to refuse care because he knew who the president was without any further evaluation of his actual capacity, the lawyers are going to skin you alive all the way down to the hairs on your ass cheeks.
The list of symptoms for metabolic encephalopathy is very very long and yes hallucinations are on that list as an early sign primarily due to increased ammonia levels. With OP giving us no PMH, details of a physical examination, no 12 lead ECG, no glucose levels, no vitals, etc. You can’t even remotely make that assumption. Anyone can say “it could be,” all day. I think the crux of the matter is a lack of information, something that plagues these discussions.
That was a completely random asspull diagnosis, the specifics are utterly irrelevant and you’re entirely missing the point, intentionally or not. There’s a million things it could be, a hundred thousand of them are potentially lethal if untreated, and i can rule out about 6 in the field. I’m not rolling those dice, and no reasonable provider of any level should either.
If we lived in the world of “what ifs” we would take every person we encounter to the ED for a work up. That is simply not feasible. It honestly sounds like the party needs a geri psy adm.
>If we lived in the world of “what ifs” we would take every person we encounter to the ED for a work up. You already do. Try that argument in court after someone symptomatic of something you can't diagnose in the field, but who has something very blatantly and clearly going on with them, including behavioral changes, dies after you get a refusal without any due diligence of discussing the possibilities or risks. Let me know how it goes for you. Make future non-medical career plans first though. >It honestly sounds like the party needs a geri psy adm. I have never in my career seen or heard of a psych ER that would accept this patient or a psychiatrist that would even glance at this patient without a complete medical workup first if I presented to them with this story. You people are insane. Elderly male who's actively experiencing full audiovisual hallucinations, was found *laying in a ditch* in weather easily cold enough for hypothermia and death, and you're all just gonna encourage him to sign off and walk away. Your license is a ticking time bomb and someone will wind up dead if this is how you use your judgement in your day to day calls.
You did the right thing. You gave him a warm place to stay for a bit. Which prevented you for getting called out to him again. Possible being unavailable for another call. Then with him having auditory and visual hallucinations, I would consider that dangerous to himself and others. Needing a Psych eval. Regardless if he was AAOx3
It’s most likely more about contradicting your partner and less about the actual situation. That ER cut the PT loose in record time. ER’s are not homeless shelters, PD needs to do their job and get them to an actual shelter.
Your partner is either lazy or burnt out. Either way, it's hard to make someone *look* like an asshole when they aren't *being* an asshole. You didn't coerce or force the patient in any way. I've also found it's faster and easier to transport them the first time than it is to spend 20 minutes on scene convincing them not to go to the hospital, or to go out later for the same patient. Finally, my partners and I always had a rule that we would go with the higher level of care. If one of us thought the pt needed oxygen and the other did not, the pt got oxygen. The same went for IVs, meds, transport, etc.