Check out the post from a few days ago that began this discussion. It has to do with the rights to refuse treatment, mental status, and medical control. I posted Chris Black’s email question to me there and I’m posting my answer to his question below:

————————

I first need to say that I hate these hypothetical and contrived situations. While they are sometimes useful to illustrate a point about no win situations, they seldom give either side a clean cut resolution with which we can live. However, here’s my take on this one:

There are two parts to this situation that both need to be addressed separately.

Number One: A patient who is CAO X 3 and refuses transport may not be taken against their will without a court order, PERIOD. There isn’t a gray area here. It constitutes kidnapping, unlawful imprisonment, assault and battery, among a whole host of other things. The feelings of the family, nursing home providers, or anyone else are not relevant. If a person is to be transported against their will by court order, I would request a call to dispatch to verify the order and perhaps police/sheriff’s deputy involvement at the scene to back that up.

Number Two: A doctor’s orders are not to be followed blindly. As the eyes and ears on the street, we are trained to use our own judgment, even at the EMT-B level to know when orders are not to be followed. In this situation, the doctor is not on the scene and has not assessed the patient. I don’t know of any doctor that deals with EMS on a regular basis that would not back off if a field provider stated very clearly:

“The patient is alert and oriented and does not wish to be touched or transported. Under my understanding of the law and policies governing my license (or certification), transporting this patient against their will in this situation constitutes kidnapping, unlawful imprisonment, assault and battery at the very least. My duty to act as an advocate for my patient leads me to accept his competent refusal of treatment or transport.”

This is a strong statement of your assessment of the situation over a recorded line (hopefully). If the doctor still presses the issue over the radio/phone. I would ask them to talk directly to the patient. Perhaps there is a medical reason to be transported of which the patient is not aware or needs to have explained. This may resolve the situation and the refusal may go away. If this did not straighten things out, I would still refuse to transport. I would contact a police agency and advise them that the patient is in danger from family members who may try to force the patient to go against their will and I would hand it over to them.

This is a mess no matter what you do. I talked to my father about this (he’s an attorney) and his take was that it’s an ethical / legal standoff. It will end badly for everyone and only be decided months or years later by a court decision. He believed based on his understanding of the situation that I am correct. In Maryland protocols, there is a clear process to follow for failure to comply with a physicians online medical order. The key points are made in two places:

First: (quoted directly from the Maryland 2007 protocols)

INABILITY TO CARRY OUT PHYSICIAN ORDER: Occasionally a situation may arise in which a physician’s order cannot be carried out; e.g., the provider feels the administration of an ordered medication would endanger the patient, a medication is not available, or a physician’s order is outside the protocol. . .

My protocol says:

1. Notify the consulting physician immediately as to the reason the order cannot be carried out.
2. Indicate on the ambulance runsheet what was ordered, the time, and the reason the order could not be carried out.
3. Notify the local EMS jurisdiction within 24 hours of the incident.

There are more details on the reporting process but the short version is all will be reviewed by the state EMS director’s office along with the jurisdictional and regional medical directors.

Second: (quoted directly from the Maryland 2007 protocols)

PHYSICIAN ORDERS FOR EXTRAORDINARY CARE NOT COVERED BY MARYLAND PROTOCOL: To maintain the life of a specific patient, it may be necessary, in rare instances, for the physician providing on-line medical consultation, as part of the EMS consultation system, to direct a prehospital provider in rendering care that is not explicitly listed within the Treatment Protocols.

1. ALL of the following criteria MUST be present for prehospital providers to proceed with an order under this section:

During the consultation, both the consulting physician and the provider must acknowledge and agree that the patient’s condition and extraordinary care are not addressed elsewhere within these medical protocols, and that the order is absolutely necessary to maintain the life of the patient. . .

Similarly to the first, the case is called in immediately and reviewed by the State EMS Director’s office and all the relevant medical directors.

I have highlighted the most important part in the second protocol citation. We both have to agree. If we don’t, the treatment or medication or whatever — DOESN’T HAPPEN!

Both situations are clearly listed in the table of contents if you wish to view the entire text. Just follow the pdf links above. In Maryland, we have a statewide protocol that I think helps with these types of situations. Cooler, un-involved heads tend to prevail when a pissing contest starts.

——————–

Too long winded for you? Okay, here’s the short answer you can take to the bank on my part:

If the patient makes an issue out of the forced transport, you could be arrested for criminal charges or charged with a civil suit. If the doctor decides to make a stink about this and your agency leadership doesn’t want to stand up for you then you might lose your job over it. I, however, would rather lose my job than go to jail.

Jamie, the Podmedic

I found this press release on interpreting health studies effectively. I think this is good reading for anyone involved in health care. Too often, we react to headlines that grab attention but leave little real information behind. It is important for all of us to be responsible media consumers. Check the story out below:

————————-

Interpreting Health Studies: Science Panel Offers Tips for Journalists

Widespread misinterpretation of health-related research, especially reports that conflate association with causation, leads to confusion and mistrust of health advice, according to physicians and scientists associated with the American Council on Science and Health (ACSH).

New York, NY (PRWEB) October 29, 2007 — Widespread misinterpretation of health-related research, especially reports that conflate association with causation, leads to confusion and mistrust of health advice, according to physicians and scientists associated with the American Council on Science and Health (ACSH).

A new ACSH publication, “Distinguishing Association from Causation: A Backgrounder for Journalists,” explains some of the basic issues and pitfalls involved in interpreting scientific studies. The paper offers tips to assist journalists and consumers in making sense of scientific reports.

“The news media are awash with headlines about the supposed risks or benefits of various foods, drugs, environmental chemicals or dietary supplements,” said ACSH president Dr. Elizabeth Whelan. “But the supposed causal connections between exposures and health effects are often conflicting or change over time,” she continued.

The ACSH report describes the different types of studies scientists use to explore links between exposures and health. In addition, it presents important criteria for distinguishing if a link between an exposure and a health effect is truly causal (e.g., smoking and lung cancer) or if the connection is merely an association (e.g., carrying matches and lung cancer). The most useful criteria include:

• Temporality. For an association to be causal, the cause must precede the effect.

• Strength. Scientists can be more confident in the causality of strong associations than weak ones.

• Dose-response. Responses that increase in frequency as exposure increases are more convincingly supportive of causality than those that do not show this pattern.

• Consistency. Relationships that are repeatedly observed by different investigators, in different places, circumstances and times, are more likely to be causal.

• Biological plausibility. Associations that fit the known biology of the disease or health effect under investigation are more likely to be causal.

“Imprudent optimism about the significance of results or the importance of a discovery can lead consumers to mistrust scientific evidence or to ignore it entirely. Unfortunately, over-interpretation or emphasis can lead consumers to believe that a harmless exposure is dangerous, or conversely that some useless or dangerous product might be beneficial,” stated Dr. John W. Morgan, cancer epidemiologist at Loma Linda University.

Download the full ACSH report, “Distinguishing Association from Causation: A Backgrounder for Journalists,” at ACSH.org.

————————–

The American Council on Science and Health is an independent, non-profit consumer education organization concerned with issues related to food, nutrition, chemicals, pharmaceuticals, lifestyle, the environment and health.

I got an email from Chris Black, a frequent contributor to the discussions here at the MedicCast. He sent me a topic idea based on an ongoing debate he has been having with another provider/instructor. It has to do with patient refusal, mental status, and medical control. Here’s the email:

————————

I had a pretty heated discussion with another medic who is also a paramedic instructor at the local community college a couple of days ago. Our discussion delt with patient refusals and transport refusals. The seneario we were dealing with was part real and part hypothetical. You get a call to a residence where an elderly patient appears in obvious resp. distress from severe chf. The patient did not call for an ambulance and does not want to go to the hospital. This particular patient is well aware of the situation regardless of the weakened condition and tells you ” I was born in this bed and I’ll die here.” Furthermore, the patient informs you that he/she knows that their condition is terminal and that the only thing that anyone at the hospital can do is prolong their suffering. upon more questioning of family you find that members of the family have called the patient’s physician who is also your MCP and he/she is insistant that this,competent patient be taken by force to the hospital. Now you must decide what to do. Keep in mind that this patient is obviously in full control of his/her faculties, only very sick and very weak.

My decision is that this is a patient who knows what he/she wants and I cannot and will not go against their decision. A patient of lawful age and sound mind can make all decisions as to his/her own care whether inside or outside of the hospital. I will however attempt in earnest to convince this patient to go to the hospital and if possible treat them to the best of my ability at the residence if transport is still refused. I refuse to force a patient to go with me unless under a court order and only with a law enforcement escort then.

My collegue has a vastly different opinion. He feels that the physician who has not even seen this patient at this particular time can decide that this patient must be forced to go to the hospital and that as a paramedic he is duty bound to follow the orders of that physician. He said that he would, indeed, force the patient to go even if he had to restrain the patient. his view is that a judge cannot force a patient into the hospital but a physician can at any time and under any circumstance.

————————

What do you think? Comment on this article using the comment link below. I’ll be posting my answer to Chris later this week but I want to know your opinion.  (Answer now posted Here)

Jamie, the Podmedic

Welcome to Episode 90

The MedicCast is a proud member of the Blubrry Podcast Network.

Right click to download this episode or click the little arrow to listen here.

A podcast for EMT’s, Paramedics, and other medical providers of all kinds.

Fill out the New Survey!

—————————-

MedicCast Listener Deals at GoDaddy.com –

Code BLU27 gets you 10% off your order at checkout
Code POD27 gets you 10% off any web hosting order at checkout
Try them out and get your piece of the internet at GoDaddy.com!

———————————

Link of the Week: The next MedicCast Live! on Wilderness EMS

———————————

News:

No Cold Meds for Kids

Adult Vaccinations for Herpes Zoster (Varicella)

Why Flu Spreads in the Winter?

AMD Telemedicine Kits

———————————–

Tip/Trick of the Week — ARDS (Acute Respiratory Distress Syndrome)

National Heart Lung Blood Institute on ARDS

———————————–

Med of the Week — Alpha and Beta Effects

Autonomic Nervous System Wiki page

———————————–

Visit the MedicCast Forums

———————————–

Thanks for Supporting the MedicCast!

Rate the podcast at iTunes or at EMS Village or Vote at Podcast Alley

Visit the MedicCast Store!

Get the New MedicCast Newsletter — Sign up now — it’s free!

Other Podcasts: MedicCast News, MedicCast Live, and Headliner News Roundup

Contact Me!
Call the Voice Mail Line — (941) 306-3342

send me a note at podmedic@mac.com

————————————————

Music from the Artist Matthew Ebel — with the song “Nothing”

Check out Matthew’s music on his site

Or — you can click on the link below to go right to iTunes to check out his music!

————————————–

Until next time, Scene safety, BSI!




This work is licensed under a
Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 United States License.

Medical News today is reporting on research into why kids with asthma are more susceptible to attacks triggered by the common cold than adults with asthma. The researchers are looking at recently discovered cellular differences in the linings of adult asthma sufferers’ lungs that may lead to better treatments for them. These cell differences could point to why kids suffer differences in asthma triggers.

Whatever they discover, we will need to be on our toes in the coming months of the Flu Season as we encounter more individuals with exacerbated respiratory issues in the field. Take some time to bone up on your respiratory protocols. Look over the medical indications or contraindications or cautions for some of your less frequently used drugs like Terbutaline.

The time to refresh and review is not with a patient while he’s tanking!

blubrry.com

Just when you think it is safe to work in DC EMS again, another issue crops up — two, actually.  A recent trainee death from respiratory distress is questioning the assessment performed by a DC EMS veteran paramedic and has caused her suspension pending investigation.  On top of that, the DC Fire and EMS Academy reported a MRSA outbreak among the trainees.
——————————

I report on this and other EMS news in the most recent episode of the MedicCast News at the Podcaster News Network.

Jamie

the Podmedic

In Day Two of my stress follow-up stories, I found this article from Medicine Net that looks at the a study on the effectiveness of Post Traumatic Stress Disorder (PTSD) treatments.

The researchers in the review study looked at other, previous studies on a variety of treatments applied to PTSD patients in an effort to determine the value of each one.  What they found, though, was that the original studies themselves were often flawed and untrustworthy.  The authors of the recent review commissioned by the Department of Veterans Affairs said that they were unable to effectively test the value of any of the studies and could not say which, if any, were effective treaments.

They did point out that they are not saying that the treatments are not effective, just that the studies that looked at their effectiveness in the past are often flawed in their construction and offer uncertain value in their conclusions.  This is unfortunate because the Department of Veterans Affairs was hoping to ascertain a definitive advantage of some treatments over others in an effort to better treat those returning from the wars in Iraq and Afghanistan.

I would be interested in whether those original studies were (A) funded by federal funds or (B) run by or set up by companies or organizations with a vested interest in a certain outcome?  This is definitely one of those — Things That Make You Go Hmmmm.

After the great response I received from listeners about the Stress in EMS MedicCast Live Episode, I thought that I should keep an eye out for stress related stories in the news.  Low and behold, not one, but two, pop up on my radar almost immediately.

The first has to do with a study that has identified a possible genetic link to why some people handle stress better than others.  You know what I mean.  Why some people become sniveling bowls of jelly (everyone else) at the drop of a pin while others can stand in the middle of a disaster and seemingly hold the world together with their bare hands (us - of course)?

I say that with a bit of a humorous tone, but it is a serious topic.  Scientists have identified specific neuro-transmitters in the brain that are involved in the sending of messages while under stress.  It appears that while some of us are able to suppress excess dopamine production aind inhibit over-response to stress, others exhibit progressive increases of dopamine production and release based on levels of external or perceived stress.  This may explain why some of us seem to thrive on stress and can wade through it all day long without perceived effects while the rest of us are wearing our hearts on our sleeves.

This discovery may point to more advances in the treatment of depression and anxiety down the road and certainly points to the idea that many of the so-called psych issues we deal with and treat are just manifestations of physiological and chemical differences in our brains.  Check out the whole article here.
Check back tomorrow for the next stress related story!

The new issue of Fieldmedics, the Magazine is available for download. You can pick it up or subscribe for new issue notification here.

The issue focuses on education in EMS and has a wide variety of articles inside to check out. I provided a column entry on being innovative in planning interactive training that can be found on page 10.

Download a copy of the pdf and check out all of the good content. I’m already working on my next piece for the November issue.

Jamie, the Podmedic

Welcome to Episode 89

The MedicCast is a proud member of the Blubrry Podcast Network.

Right click to download this episode or click the little arrow to listen here.

A podcast for EMT’s, Paramedics, and other medical providers of all kinds.

Fill out the New Survey!

—————————-

MedicCast Listener Deals at GoDaddy.com –

Code BLU27 gets you 10% off your order at checkout
Code POD27 gets you 10% off any web hosting order at checkout
Try them out and get your piece of the internet at GoDaddy.com!

———————————

Link of the Week: Listener Rob’s Diabetes Tattoo Link

———————————

News:

Cambodian Native Gives Back

Malaria Vaccine Progressing

Top Hospitals = Better Survival Rates

More MRSA Deaths Than AIDS in U.S.

———————————–

Tip/Trick of the Week — Renal Failure Signs and Symptoms

NIH Medline on Acute Kidney Failure

NIH Medline on Chronic Kidney Failure

———————————–

Med of the Week — I.V. Fluids Review

Wikipedia IV Fluids and Access Page

Nursing Article on IV Fluids and Fluid Balance

———————————–

Visit the MedicCast Forums

———————————–

Thanks for Supporting the MedicCast!

Rate the podcast at iTunes or at EMS Village or Vote at Podcast Alley

Visit the MedicCast Store!

Get the New MedicCast Newsletter — Sign up now — it’s free!

Other Podcasts: MedicCast News, MedicCast Live, and Headliner News Roundup

Contact Me!
Call the Voice Mail Line — (941) 306-3342

send me a note at podmedic@mac.com

————————————————

Music from the Podsafe Music Network by Carlina — How Long Will You Be Gone?

————————————–

Until next time, Scene safety, BSI!




This work is licensed under a
Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 United States License.

� Previous Entries