EM Tricky stuff... assault vs restraint

[pinipig523]

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So I had a patient who was suicidal want to sign out ama... somehow I convinced them to stay. Pt was AOx3 and appeared competent...I figured that suicidality would lock them in for eval by psych/whichever inpatient facility mobile unit there was.

Thoughts? Or would you say that they can? Or is this something that is county dependent?

Also - similar topic - when is medical care classified as assault and when is it indicated? An altered patient is AOx2 and wants to leave but was brought in by EMS because family thought he was altered? A prisoner brought in by police but he refuses iv stick?

Sometimes, it's not the EM stuff that's tough, it's all this social stuff.

 

[EM2BE]

So I had a patient who was suicidal want to sign out ama... somehow I convinced them to stay. Pt was AOx3 and appeared competent...I figured that suicidality would lock them in for eval by psych/whichever inpatient facility mobile unit there was.

Thoughts? Or would you say that they can? Or is this something that is county dependent?

Also - similar topic - when is medical care classified as assault and when is it indicated? An altered patient is AOx2 and wants to leave but was brought in by EMS because family thought he was altered? A prisoner brought in by police but he refuses iv stick?

Sometimes, it's not the EM stuff that's tough, it's all this social stuff.

I can answer mostly to the first part as I have had a lot of patients with this. If suicidal / homicidal, they can be locked in for eval and psych placement. Medical and/or physical restraints. If they don't agree to stay, I commit them as an involuntary psych hold. Involuntary unfortunately will stay on their permanent records (from what I hear it shows up when they are looking for jobs even). I try to tell them it's better to sign in voluntary, but if they refuse, I will fill out the paperwork.

The next topic is much more complicated. I think I would have to take it case-by-case to see the patient and make the determination. That's the easiest answer. When family bring in a patient, they will convince the patient for me for tests which need to be done. It's more unfortunate when the family says it's up to the patient. I will explain everything, risks and benefits of whatever test, then say "I'm going to leave the room to give you time to decide." Usually the family member works some magic while I go see someone else. By the time I return, they reach a conclusion. If it's still no, the family member is in on the decision. If no family is present, it's a lot harder. If they seem with it enough to make decisions and accucheck is fine, I don't force anything. I just have a conversation with them. I also try to contact the family if they aren't coming in, but often EMS will tell us they are on their way, so we wait.

I haven't had too many prisoners. Not sure what laws exist there.

 

[deleted77919]

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[la gringa]

what i usually tell people in custody is that the officer won't take them to jail until they are medically clear, and i can't medically clear them w/o X or Y test. if it's a relatively minor offense especially... they often want to get done and get going. others want to delay getting to jail. it's rarely a big issue once i put it that way.

we don't get prisoners in my current gig... totally different beast.

 

[UnderwaterDoc]

Prisoners can refuse any and all medical testing. So long as they understand risk/benefits they can refuse your history/exam/rads/labs whatever. This is the case even if they are brought in for "medical clearance."

If the police need blood/whatever for their case they have their own process for collecting that against someone's will (in our system they send a nurse from the nearby jail). Helps maintain chain of evidence.

I had a recent experience with a prisoner that was interesting to say the least. Guy is brought in by police after he was found dealing cocaine, police allege that he stuck a bunch of cocaine baggies up his butt hole, and they bring him in because they are "worried" that when the baggies rupture he will die, and furthermore they want the cocaine for evidence. Needless to say the guy is adamantly refusing a rectal examination, won't even let us near him. After some deliberation we end up calling the hospital attorney and getting in touch with a local judge that grants a warrant to search him, we then propofolize him and examine his rectum and sure enough, he had four baggies stuck up in there full of what very much looked like cocaine.

I'm not sure if there is a legal precedent to this, or what the cops' protocol is for these situations, but they certainly seemed like they wanted nothing to do with it. I guess the guy could very well die/have significant morbidity if the baggies ruptured in his colon, which would go along the lines of self-injury which we are required to prevent. Thankfully the rest of the prisoners we see are usually much more cooperative.

As far as the psych and altered patients agree with what was said above, if suicidal/altered = cannot refuse admission/treatment = sedate and involuntarily admit/sedate and involuntarily treat

 

[Apollyon]

I had a recent experience with a prisoner that was interesting to say the least. Guy is brought in by police after he was found dealing cocaine, police allege that he stuck a bunch of cocaine baggies up his butt hole, and they bring him in because they are "worried" that when the baggies rupture he will die, and furthermore they want the cocaine for evidence. Needless to say the guy is adamantly refusing a rectal examination, won't even let us near him. After some deliberation we end up calling the hospital attorney and getting in touch with a local judge that grants a warrant to search him, we then propofolize him and examine his rectum and sure enough, he had four baggies stuck up in there full of what very much looked like cocaine.

I'm not sure if there is a legal precedent to this, or what the cops' protocol is for these situations, but they certainly seemed like they wanted nothing to do with it. I guess the guy could very well die/have significant morbidity if the baggies ruptured in his colon, which would go along the lines of self-injury which we are required to prevent. Thankfully the rest of the prisoners we see are usually much more cooperative.

As far as the psych and altered patients agree with what was said above, if suicidal/altered = cannot refuse admission/treatment = sedate and involuntarily admit/sedate and involuntarily treat

Maybe I am mis-reading this, but that sounds contradictory (as to the bolded sections). If you are referring to someone other than the police in the second bolded part (with the "they"), I do not know to whom it is that you refer.

 

[TysonCook]

At our shop:
1) Suicidal can't sign out AMA. You can IVC them and restrain, or speak with them, and determine if they are no longer suicidal, and DC them with depression Dx.
2) I do not sedate people for rectal exams. I DC them back to jail with a note saying expectant management, search their feces when they defecate, bring back for any changes.
3) In NC you can restrain a person in Jail custody for legal blood draws and urine:

"The statute now requires a physician, registered nurse, EMT, or other qualified person to withdraw a blood or urine sample without any authorization or consent from the patient. Under CHS policy and as allowed by law, the law enforcement officer must sign a written certification confirming the request... Both the person withdrawing the sample and the facility are immune from liability for complying with this statute." N.C.G.S. § 20-139.1: Procedures governing chemical analyses

 

[dotcb]

1. detain the suicidal patient

2. ability to accept or refuse care is a clinical judgement based on patient's ability to verbalize understanding of information, benefit, and risks. You have to decide if a person has this ability or doesn't. If they don't - treat them with the right care. If they do, they can refuse/accept. It also may be action specific. They may have ability to make some decisions but not others. There is also a measure of gravity of the situation. It's a matter of degrees. Doing a blood draw is much less harmful to a patient than, say - doing an operation under general anesthesia against their consent. May occasionally need to get a psych consult if you can't determine ability to make informed decision and the gravity of the situation is extremely high. But most of the time, the EP should be able to make most of these situations.

3. In my state, prisoners can refuse most things except prison.

 

[UnderwaterDoc]

Maybe I am mis-reading this, but that sounds contradictory (as to the bolded sections). If you are referring to someone other than the police in the second bolded part (with the "they"), I do not know to whom it is that you refer.

Cops wanted nothing to do with actually removing the baggies from the dude's rectum, hence they brought him to our ED, so we could do it for them.

To the person above that stated that they would not sedate for a rectal in this situation. What happens if the baggies break and the guy dies/gets a necrotic bowel?

 

[Rendar5]

Cops wanted nothing to do with actually removing the baggies from the dude's rectum, hence they brought him to our ED, so we could do it for them.

To the person above that stated that they would not sedate for a rectal in this situation. What happens if the baggies break and the guy dies/gets a necrotic bowel?

AMA refusal of procedure

 

[Apollyon]

Cops wanted nothing to do with actually removing the baggies from the dude's rectum, hence they brought him to our ED, so we could do it for them.

Ah, gotcha. Thank you for the clarification.

 

[Daiphon]

Cops wanted nothing to do with actually removing the baggies from the dude's rectum, hence they brought him to our ED, so we could do it for them.

To the person above that stated that they would not sedate for a rectal in this situation. What happens if the baggies break and the guy dies/gets a necrotic bowel?

Stuffers don't usually die. Packers do. I obs the former, and typically admit the latter.

http://www.ncbi.nlm.nih.gov/m/pubmed/20825819/?i=2&from=/21524877/related

http://www.ncbi.nlm.nih.gov/m/pubmed/19386860/?i=6&from=/21524877/related

Cheers!
-d

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