Ground Level Fall

As I'm returning to the station from my ITLS (International Trauma Life Support) class with Drew, I hear the tones drop for a ground level fall. I'm almost 100% sure that we won't be going, but Drew grabs my arm as he heads for the medic.
"Let's go," he says with a sigh.
"Why us!?"
"Everyone else gets off in an hour; we're here all night. Let's go."
Eric, Drew and I climb into the medic, and I'm beyond frustrated. I'm tired from class, I have studying to do, and to top it all off I'm missing the lunar eclipse. I call my mom en route so I can hear her describe the eclipse.
"Blood red," she says. "You won't see this again until 2010, so try to look up when you get to the house." The sirens wail in the background, and since Eric is driving, the airhorn drowns out smatterings of what my mom is saying.
"Jesus, Eric" I hear Drew say as we approach the intersection, "they heard you coming an hour ago!"
When we get to the house, I see a woman lying on the floor of her bathroom, strategically wedged between the bathtub, the door and the bedroom.
"Hi, my name is Sam; I'm an EMT with the rescue squad. Try not to move your head, just answer my questions verbally; I'm going to put my hands on your head, is that okay?" She shakes her head to say yes, and I groan.
"What's your name," I ask her with a smile.
"Wendy," she replies. "I feel so stupid."
"Why stupid, Wendy?"
"I fell and hit my head on the bathtub and my friend called the ambulance and now here you are. The neighbors must think I'm so stupid." I smell the alcohol on her breath, and I ask her if she's been drinking.
"God yes," she replies, "lots."
I notice a nasty laceration at her hairline; it's stopped bleeding, but I can tell it hurts. She has a pretty bad bruise on her cheek, too. Eric shines a light for me to see better, but has the uncanny ability to shine it right in her eyes. I ask him to turn it off, and she smiles and whispers, "thank you."
I ask Drew to get me a C-collar, and as soon as I say that, Wendy looks up at me and says as serious as a heart attack, "I'm not going to the hospital."
I shoot a look over to Eric and sigh. He asks her the standard questions: person, place and day. She answers them all beautifully, and he tells me to let go of c-spine. Reluctantly I do, but not without protest.
"She's drunk."
"She's A&O x 3. She can refuse."
"I don't care. She's drunk and she hit her head hard enough to bruise and slice her scalp open." I look over at her, and see that she has her eyes closed. "Wendy," I ask, and she opens them slowly.
"Wendy, are you okay?"
"My hands feel tingly," she says, and I look very pointedly at Eric. I take her hands in mine and ask her to squeeze; she does, and when she's finished, she looks at me and says, "will you just hold my hands?"
"Well sure," I say slightly confused.
"My hands just feel so much calmer in yours." I sit next to her and hold her hands in mine, squeezing them every so often to see if I get a response. I'm not ready to leave her just yet.
"Did you black out when you fell?"
"Do you know why you fell?"
"Because I'm drunk."
"Do you remember falling?"
"No," she admits with a sigh. "But I do remember you getting here, and I can tell you my last name and everything."
I ask Eric to call medical control to see if we can't treat this as implied consent, what with the alcohol consumption, and head injury with memory loss.
As he does, I talk to Wendy.
"Do you feel nauseous, dizzy or weak at all?"
"No," she says hesitantly.
"Are you lying to me to get me to go away?"
"I'm just tired." I don't like that answer, so I try to keep her awake.
"You know, if you don't let me take you to the hospital, I'm going to go back to the station and sit up all night worrying about you."
"I just want to sleep."
"So do I, but I won't be able to if I don't know you're okay."
"I'm okay. I promise I'm okay." She squeezes my hands as if to prove her point, and then she looks me straight in the eye. With a little crack in her voice, she says "I'm really sorry."
"Why sorry?"
"Because I fell, and I hit my head, and now you're here. And you shouldn't have to be here. This is my fault. And I'm drunk. And here you are, holding my hands and worrying about me. Don't worry about me."
"Let me take you to the hospital then."
"I don't want to go to the hospital."
Just then, Eric comes back.
"Doctor says that if she doesn't want to go and she's A&O x 3, then she doesn't have to." I look him in the eyes, begging him to call the doctor back and tell him something--anything--that will make him change his mind. I look to Drew for support, but he looks back at me helplessly.
"Yes Sam," she replies, obviously pleased with herself for remembering my name.
"You have to make me a promise."
"If you start to feel worse once we leave--and I mean worse in any way--you will call us back. If you get nauseous, dizzy, weak, or you just feel a little funny, you will call 911 and tell them to send us again."
"I promise."
"I'm not done," I say, and she laughs. I stare her down sternly, and she stops, looking back at me earnestly. "Tomorrow morning, you will go see your doctor and you will get that stitched up." She tears up a bit and nods.
"Okay. I promise."

As we leave, Eric sighs. "EMS is just a game of cover-your-ass," he says. "At least if something happens, it's not our fault."
"I don't care whose fault it is," I say through gritted teeth, "she needs to go to the hospital. If something happens, I will never stop beating myself up for not carrying her out to the medic over my shoulder." I look at my watch and see that it's 11pm. Longest scene time of my life.
I look up, but the eclipse is done.

[[So normally I don't ask for feedback, but I'd like to know your opinion. I believe that since she was intoxicated, she was not in her right mind, and even though she was "alert and oriented", she was still not in a state of mind to make decisions. Eric believes that since she could answer our questions, she had the right to refuse. We both agree that we covered ourselves legally by contacting medical control. But with our hindsight-goggles on, what should have happened? She didn't end up calling us back, so I assume that her friend who stayed the night made sure she was okay. Thoughts, feelings? I know that personally if it were my family member, and I weren't there when it happened, I would want the EMS personnel to call PD to get a temporary custody order. Anyway, let me know.



Odie said...

It's a sticky wicket, that one. Shes of age, shes CAOx3, shes answering appropriately. Thats grounds for right to refusal right there.

Taking her against her will could have left you open to assault charges. Which sounds silly as all hell but its a really litigious society. Our doc would have told us the same thing. The two "greentags" from the head on collision the other day really probably should have gone to the hospital considering the MOI and the lack of airbag deployment. But they were able to meet the criteria for refusal. So they went home with their stoner friend.

Life sucks sometimes. I'm sure if the friend called the first time for the fall. If something worse happened to her i'm sure 911 got a call back.

No worries Sam, No worries. Just the sucky part of the job coming out.

Scott said...

In that case, you HAVE TO let them refuse. I know it is sad, but the choice is the person's to make, whether we agree with it or not.

I am so glad I stopped my oncologist from further "treating" me with additional chemotherapy. He might feel I made the wrong decision, but I don't.

And now I am dealing with a friend who is in an abusive relationship. I would love to drive over there, carry her to my car and whisk her away to a safe place. But she doesn't want to leave, and there is nothing I can do about it FOR her.

The right to choice is a basic human right, whether in healthcare or any other part of life.

Paula said...

I konw what you were thinking. I would have been just as worried if I was her EMT. But apparently she was well within her rights to refuse hopsital care... =\

On a different note, I have gotten my books for my class! I hope that I can start my classes and get certified soon. If I become half as caring for my patients as you are, I'll be doing well.

Love you, and these posts make my life.

Kyle J. said...

If i had a partner like Eric, i'd want to die.

Anonymous said...

That sucks. Sorry you had to deal with that sam.


Medic Student said...

Refusal is the right of any patient. I personally believe every person has the right to make decisions for themselves and for their well-being, and if that means it may hurt them, the only duty that I have is to inform them of the harm that may occur as a result of their choices. Just like any other choice they might make - things could go wrong.

Yes, I don't want people to get hurt. That's just how it goes. I won't last long in this job if I let things like this get to me... as sad as it is, you have to remain slightly emotionally detached in order to survive.

EE said...

Document well and don't worry.

Anonymous said...

This was a great story...but Meris, I have some great news:

I signed my name in the membership book yesterday afternoon!!!

You do not know how blessed and happy I am. It means a lot to join the church because I have talked about and talked about it...and I realized that I could simply choose to do this. That and the true wish that, I hopefully will decide that I will choose to be a member of CUUPS or to be associated with the Full Circle group that members of the church has started.

Oh and yea, Sam, it is life. Don't say that I didn't read it...I did...I just, wish to say that I liked it. Let the others who are in the know, speak about technical details and such...Anyway baby-girl, be blessed...

and remember that, you are still a true hottie! You are intelligent, with very nice curves, a wonderful soul, and you are absolutely world class that anybody would just love to get to know...

Scott said...

Sam, you did the best you could for that woman.

Now, I have to say that you are really cool! "Morphine in a bottle!" I love it! Great minds think alike.

RevMedic said...

Our protocols do not allow us to obtain refusals from intoxicated patients. Our doc is a stickler on that one, too.
People who have been drinking are usually not considered to be reliable and obtaining a signed refusal may be an inappropriate one.
If you have further questions, contact this nice lady, who's an attorney and a paramedic:

Anonymous said...

Ugh...another one of those "gray" areas of EMS...She's an adult of legal age who is AAOx3 and by most rights that allows her to refuse care. However, she is intoxicated by her own admission. You did the right thing by contacting med control - unfortunately the doc didn't share the same point-of-view as you did. What does your policy outline for dealing with these type of patients? If it doesn't address this issue specifically, it may be time to re-visit and re-vamp. Document well...very well. Get law enforcement involved if available - even if they don't take her into protective custody, they provide the benefit of witnessing her refusal of care.

Dad said...

The concept of "informed" refusal by a mentally impaired individual (be it temporary, such as drugs or alcohol, or permanent, such as Alzheimer's or retardation) is a fluid and variable consideration. For example, an mentally impaired person may very well be capable of making an informed refusal of a simple thing like a blood test or tetanus shot. However, the mentally impaired person may not be able to understand the seriousness of a potential skull fracture or subdural hematoma from a fall.

In the first scenario, there is little harm that will come from letting the temporarily impaired individual recover and then re-present the request.

In the second scenario, such delay in evaluation and treatment can have significant consequences.

A hard and fast policy denying an intoxicated person's right to autonomy and informed refusal will lead to overtreatment. The opposite is also true.

As is often true elsewhere in life, each case must stand on its own merits. The important thing I learned from reading this report is that there is a responsible medical backup upon whom you can rely for help in making these tough calls.

Bernice said...

This is an old one, but I have been catching up on your blog since finding it. I recently had a similar situation and asked for some guidance on my own blog. Thinking about your case and putting myself directly in your shoes, I can safely say, I would have the same reservations. Everything you covered keeps you legally free of any legal action, but then there is that pesky heart of yours getting in the way. (This is said comepletely tongue-in-cheek.)

She had the right to refuse and technically, the mental capacity. The only other thing I would think of doing would be to talk to whomever called 911 for her in the first place and let them know the issues at hand and the signs to watch for. At least then there is someone who is (presumeably) of sound and sober mind that can keep an eye on things.

I despise these grey areas with a passion. I understand your reservations but you did the best you could.