The only reason we get away with giving such large doses of epinephrine to these patients is that they are already dead.

- Rogue Medic

Round 4 of Happy Medic’s Rules for Kidnapping

There is a post on this at The EMT Spot and I am continuing from Round 1, Round 2, and Round 3. I did get to talk with Happy Medic about this at EMS Today and we seem to be in agreement about the problem.

The problem is that we have protocols that do not do a good job of differentiating among the different patients refusing treatment and/or transport, but we are expected to intuitively know which patients are too critically unstable to be allowed to make decisions for themselves.

Most people seem to agree that a patient can life saving care with the full understanding that this will probably result in that patient’s death. I know that refusing treatment means that I will probably die today. I have a terminal illness and I can only change the location of my death by going to the hospital. I want to die here, at home, with my family.

We may not be comfortable with the decision, but we understand that there is not legal or moral for us to prevent a competent patient from making this decision. Competent meaning that the patient has the capacity to understand the decision being made.

That is the easy decision. The difficult decision is the unexpected, and much less likely, possibility of death due to trauma. What do we do when our patient meets trauma alert, but does not want to go to the trauma center?

At what point are we able to substitute our judgment for the patient’s judgment?

Based on what?

Some may insist that we will not just be sued, but lose the lawsuit and that is what is most important. We may respect individual rights, but when the rights of others might cause us discomfort, the rights of others do not matter.

Trauma criteria produce a life-threatening, or limb-threatening, appropriate triage rates that are ridiculously low.[1], [2], [3]

We are supposed to prevent a patient from making a decision without even attempting to assess the patient’s capacity to make decisions, because we are the experts. This desire to be protocol monkeys is never good.

We are embarrassingly inaccurate, but we are the experts?

The 6.5% overall appropriate triage rate almost reaches a 95% confidence interval for being able to predict that patients do not need to go to a trauma center. If we eliminated the patients who are unconscious and clearly lacking capacity to make decisions, we might even reach that p value of 0.05. Maybe it depends on how we define expert.

Wrong 93.5% of the time

In what way does that suggest expertise?

Using these criteria, we would have to transport an average of over 15 trauma patients, in order to be able to transport just one legitimate trauma patient.

If we are going to deprive people of their rights, because of the critical nature of their illness, or injury, shouldn’t we have some specific protocol stating when a patient will not be permitted to make decisions for himself, no matter how much capacity to make informed decisions the patient has?

Do any of us have such a protocol?

Also see Medic 51, who apparently started this whole topic with the well written Kidnapping Patients and the commentaries by The Social MedicGet Over Yourself Bloggers – On Opinions, Passions, And Blogs and by EMT-Medical StudentWhy some discussions are more pertinent than others and the post that started it all – Kidnapping – The Cowtipping of EMS.

Footnotes:

[1] Differentiation of confirmed major trauma patients and potential major trauma patients using pre-hospital trauma triage criteria.
Cox S, Smith K, Currell A, Harriss L, Barger B, Cameron P.
Injury. 2011 Sep;42(9):889-95. Epub 2010 Apr 28.
PMID: 20430387 [PubMed - indexed for MEDLINE]

[2] Trauma Criteria – preventative medicine – Part I
Rogue Medic
Sun, 26 Feb 2012
Article

[3] Trauma Criteria: preventative medicine? Episode 37
First Few Moments
February 26th, 2012
Podcast

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Comments

  1. Maryland is implementing a statewide protocol on July 1st that will attempt to address these issues. I have taken an excerpt of it from the MD state protocols and posted it on my blog for all to see as it’s also a great tool for teaching students about patient refusals.

  2. Whoa, whoa, whoa. How dare you discipline the protocol monkeys? If you do that, when you have a thinking individual/person/paramedic(mutually exclusive there?) do a good job and foul up once for not following the holy book of protocol, how can you discipline him too? Because if we discipline protocol monkeys, the one that doesn’t follow said protocols should be let off because they actually thought and tried rather than “I just did it because the protocol says ‘see A, do B’, and that’s all that matters”. And if we did that, would we really need as many QA/QI/CYA/PYAIAS(put your….in a sling) people as we need? And if we do that, are we helping the economic recovery because YES WE CAN!, and won’t someone PLEASE THINK OF THE CHILDREN?!?!?

  3. Rogue,

    You’re not going to cut Justin a break on the post title, are you? :-)

    The problem with mis-triage is not really central to this discussion. Mis-triage certainly makes the problem worse; but even if we could magically get 100% accuracy on trauma triage, we’d have to deal with people refusing transport.

    Some people think all docs are pill-pushing quacks and avoid hospitals in favor of alternative medicine, some have religious reasons for non-treatment (e.g. Christian Scientists), some are more concerned about money and will roll the dice with their life to avoid a hospital bill. All of these people can be perfectly oriented and rational based on their belief axioms; at what point is it ethical or legal to tell them that their basis for decision is not acceptable?.

    There is already one group of people that we legally kidnap all the time: suicidal people placed on psych holds. We’ve all transported people who are completely competent…except they think taking their own life will solve problems for themselves or their family/friends. Given that we can bind the slashed wrists of a suicidal patient against their will, why can’t we equivalently say that anyone who refuses treatment/transport for xyz critical condition or injury is de facto suicidal and have them transported as a psych hold?

  4. Interesting that you would bring up mistriage.

    At a recent major fire where I work, the entire management of the incident was changed when EMS identified several of the injuries of the burn victims as specifically chemical, probably from a meth lab. How they came to the meth lab conclusion, I’m not sure. Possibly because the incident started with an explosion.

    They were wrong. None of the burns were chemical.

    Ultimately, everything still went well, but one simple mistake completely changed the course of the incident, not simply for EMS, but on the Fire, PD, and FMO side, as well as Emergency management.

    I’m not trying to rag on the crews involved, as I was not there and cannot judge their actions.

    I just think we forget how far reaching the implications our own decisions as providers can be sometimes.

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