He’s a good guy until his sugar level tanks, then he turns from Dr. David Brenner into the Incredible Hulk. Normally we treat him at his workplace and let him sign off, but today he needs to go. Not that today is any different from the other times we have been called to the welding company where he works, but the frequency of the calls makes it apparent that he needs to be evaluated.
He’s sitting on a chair in the warehouse, guys working around him. I have four firefighters from Engine 13 with us. Me and Brian could handle him, but with resources at our disposal it would be ridiculous to do so. Two people subduing an aggressive patient would need to use excessive force, and somebody would probably get hurt. With four or five people, the patient is completely overwhelmed, nobody needs to get carried away and everything goes smoothly.
We pluck him from his seat and put him onto the stretcher. I tell his boss that we plan on kidnapping him while he is out of it, taking the option of a lucid refusal away from him. I’ll give the D-50 en route. The boss is happy, I’m happy, the guys from Engine 13 are happy, and “John” is nearly unconscious but still full of fight. 
The plan works perfectly. I’ve got Ryan and Brian in back with me, another firefighter driving and the other two following in the engine. The IV goes in, the medication follows, and John comes around, just in time to see the ER as we back into the bay.
“Where am I?” he asks.
“The ER, your blood glucose was 27, you had to go.”
“I need to stay at work, I need that job,” he tells me, trying to get off the stretcher.
“You need to get your glucose level under control. John, this is the third time this month. Your brain can’t take much more.”
“I guess.” He sits back in the stretcher and we wheel him in.
A fire department based EMS system is the most effective way to deliver quality patient care to the community. When the people assigned to those fire companies are trained and motivated, which they are in Providence, nothing beats it.
Excellent approach.
Consider the term “false imprisonment”
Any model of system can work as long as everyone involved is professional, participates fully, and put the patient first.
I’m ok with “implied consent”.
I don’t like the statement “I tell his boss that we plan on kidnapping him while he is out of it, taking the option of a lucid refusal away from him.” If you can fix the immediate problem in the field. Which you CAN in the case of hypoglycemia, then do so. When he is lucid again then present your arguement to him that you think he needs to go get evaluated; letting HIM decided for himself what he wants to do.. It is his body, his health. Also in regard to the statement “The boss is happy, I’m happy, the guys from Engine 13 are happy..”, Honestly who cares if all those people are happy. The real question is, is the patient happy with what you did? That is the person’s opinion who should really matter in this situation. While I am sure you only had the patient’s interest at heart, and technically you might not of violated the law, I just don’t agree in how you handled this..
Are you FREAKING KIDDING ME???
You’d delay treatment of a perfectly correctable medical condition in order to remove the possibility that the patient might exercise his rights? You used the word “kidnap” in there, which is ASTOUNDING to me.
What if he puts up a fight and hurts himself, or somebody in your crew? As a paramedic student I watched a terrible fire based EMS crew wrestle a guy down, causing a fractured wrist…oh and they also missed the freaking IV, and the “superior” fire/medic got his OOMPH into it and managed to get half an amp of D50 into the guys elbow before the student managed to get the confidence to say something.
I understand he’s a PITA, and needs evaluation…but he also has rights, and one of those is to be an idiot.
If THIS is an example of the “nothing beats it” system in Providence, you are truly the most deluded guy in the fire service. I wonder if anybody from your crew of from your service…or your medical director will have the sense to remove your practice privileges and turn you in to the state board before you get somebody hurt or sued?
You realize the patient has a FANTASTIC case against you and the department, right?
Scott Brown
FF/Paramedic
Houston
This ain’t my first rodeo, fellas. Twenty years, tens of thousands of calls, zero complaints, dozens of letters of thanks and I sleep like a baby when my day is done.
What I don’t think Jason and Scott realize that RI has no procedure for treating and releasing diabetics, nor a protocol that allows for it. So technically, what they’re suggesting is actually more dangerous legally than what Mike actually did.
I think its hard to push D-50 when a patient is fighting with you.
Also if a patient needs IV glucose on three different occasions in the same month then he is starting to abuse the system. If he has to go to the hospital every time this happens I think he’ll start to be a little more careful at monitoring his sugar.
I think you made the right call in this situation Lt Morse.
I don’t know why so many people, thankfully they don’t last here, find it necessary to post negative comments on other peoples blogs. Start your own blog if you want to complain. This guy was treated within the scope of all state protocols, and his best interests, and those of his employers were looked after.
Assuming of course, that this event actually ever even happened.
I’m not entirely sure how one might get more legally in jeopardy than going on the internet and use the word “kidnap” and the phrase “…taking the option of a lucid refusal away from him”, despite the ethical issues.
Anyhoo, at the very least its provided my students with a real-world example of the precise wrong thing to do.
I have a great idea; buy copies of my book for all of your students and they can get a whole booksworth of examples of what not to do, and in the process get some real world knowledge. And I guarantee they will be better paramedics.
As for legal jeopardy over a blog post that may or may not even be real, I will also guarantee that there IS no legal jeopardy whatsoever.
Lighten up, Houston paramedic, its a big world out there, and a lot of ways to get the job done. If you had read the post without looking for ways to show your superior knowledge, you probably would have noticed that I knew the patient who may or may not be real, knew his employers, who also may or may not be real and ultimately the best course of action was taken.
Remember, we are here for the patient, not our own ego.
“A fire department based EMS system is the most effective way to deliver quality patient care to the community.”
Bull like this didn’t need to or have any relevance to the article. Are you talking chronic hypos or brawn over sugars?
As someone who has done the kidnapping in non fire EMS “State” it took quite a few attendances before it happened. After 5 years of attendances and name calling from a diabetic incorrectly who saw hypos as weight loss, we eventually incorporated kidnapping.
What should be happening is that a Supervisor attends this patients and tries to work out a solution, even with his Dr. The kidnapping is a last resort and doesn’t guarantee an outcome; he wakes up and leaves when he wants to AMA. We had the same high ideals of fixing this guy via the system and it just doesn’t work.
Giving outpourings of your actions to his boss is unprofessional (Don’t care about your privacy laws) but don’t make the patient out to be a tool in front of his boss. Keeping the knuckle draggers happy too isn’t a concern in managing this patient as a professional no matter how his actions tick you off. His brain can actually take more than 3 hypos let me tell you.
I’m glad you highlighted a real scenario though.
And for what its worth the Hulk was Dr Bruce Banner!
Cannulator, I am the supervisor.
I find it amazing that a paramedic, and even worse, an instructor, would question the proper care of this patient. He was found in a semi-conscious, combative state in a busy warehouse where he operates a forklift. He has a known history of Insulin dependent diabetes. His blood glucose was 27.
Rather than treat him in the dirty warehouse he was moved to the rescue, where en route to the nearest emergency facility he was given an IV and D-50. Implied consent? Of course! Anything but a transport of this patient is dereliction of duty. Just because I have the means to elevate his glucose level in the field doesn’t give me the authority to leave him at work. A signed refusal may help in a court of law if his glucose suddenly drops again and he kills himself or somebody else with the forklift but I doubt it. I would do the same thing 100 out of 100 times, and hope everybody else in the field would do the same.
Heaven forbid an EMT uses some colorful language when writing a blog story, some jackass from Houston will use it to make points with his students. Some days I take a look at how other people in this field operate and just shake my head.
Bruce Banner! I knew that didn’t sound right. Thanks for that.
Some creative patient care, heads up thinking. Knowing this guys medical history, and his usual track record when his glucose drops. Treating this guy on scene and sighning him off, even if your county, state or province (in my case) allows you to sign off patients, using certain criteria, in my opinion would have been the wrong thing to do. Call it concern for cleanliness, crew liability, safety of the patient after you leave, getting the patient in the back of the ambulance and treating him enroute, to ensure he gets to a hospital for MD assessment what was needed. This guy probably needs to have his medications adjusted, changed or put on different medications to control his blood sugar, along with some education on his condition and how to manage that. Things that we Paramedics and EMTs are unable to do. Good team work by those involved.
However, telling his boss you are “kidnapping him”, may not have been the best choice of words. You never know who is listening, video recording etc. I have a collegue who had a complaint filed against him by a first responder, because he chose to wait until they were in the back of the ambulance to ask his female patient medical questions of a personal nature, rather then do it infront of the first responders and her co workers. He said, “I have to ask you some more questions, but there are too many sets of ears here, so I will ask them in the ambulance.” The first responders took offence to his comment.
I still fail how this shows that fire based EMS is better than EMS that is NON fire based. I have been a medic for 19 years now in a system that has never been fire based. The team work your call discusses, could happen regardless of how your system is based. Let’s say the police were the other service on scene and NOT a fire department, and the same well co ordinated effort occured, would you say that EMS should be Police Dept. based? NOT all EMS is fire based and works very well as a separate service and has excellent working relationships with the local fire and police services. The bottom line here is patient care, NOT what service or what model it is provided.
Thanks for the thoughtful reply,T Langley-Smith. This post has gotten a little out of hand, admittedly by my own volition. I tend to assume that anybody who reads my ramblings has some history with me, either in person or through reading the blog for years now, and knows my writing style. First of all, everything I write has been pieced together from many different calls so that the anonymity of the patient is protected. The stories I tell are more human interest things than case studies, there are plenty of blogs and websites dedicated to the technical nature of our job.
The “kidnapping” thing, is probably something i thought rather than said, I really don’t remember. And the Fire Department being the best was just my way of stimulating some discussion on the matter, I’m amazed at all of the different ways we deliver EMS, here in the states and worldwide.
I learn more by doing this blog than I ever could have imagined, and hope people who read it feel the same.
Thanks for stopping by!
“Heaven forbid an EMT uses some colorful language when writing a blog story, some jackass from Houston will use it to make points with his students. Some days I take a look at how other people in this field operate and just shake my head.”
So, who were you trying to make points with? Your language is not my issue, but words and phrases have meaning, and “kidnap” and “…taking the option of a lucid refusal away from him” have meaning.
Generally, I try my best to operate without violating my patients rights and if we’re going to play the “what if” game, riding in the rig is inherently dangerous. It’d be awesome if y’all got t-boned and the guy got hurt or killed in the midst of your decision to deny him his choice in his own healthcare, huh?
Nobody you’ve ever encountered is a bigger fan of things that decrease abuse of service…again, I “get” that he’s utilizing more than his fair share of your expertise, and that its a dangerous drag on your service and a risk to life and limb of your guys because he won’t get his Bgl under control…but you have to play it straight, and if you aren’t going to play it straight, talking up how awesomely smart you are because you played fast and loose with your ethical obligations to achieve YOUR desired goal, seems like a poor choice.
If you thought it on the scene, but didn’t say it…why would you say it here? If its a composite scenario…which I stated I hoped it was initially…thank God, but again, you laid it all out here trying to make the point that you’re just the cleverest thing ever to leap off a rig.
Lt. Smith…he didn’t “treat him enroute”…he stated that he delayed treatment until they were backing in the dock at the ED. I wouldn’t really have much of an issue with treatment enroute…but that’s not what he did/said he did.
I’m also just a tad concerned about the “how awesome fire based EMS is” aspects. I’m fire based EMS, and I agree that its the logical and natural place for it…from an organizational standpoint. Unfortunately, many…and I’m admittedly ignorant of Providence’s system…fire departments provide lousy EMS…I know Houston does. The reason is, its looked upon as something you have to endure to get your coveted truck assignment. They send all new-hires to medic school and try to make good medics out of folks who don’t have the desire to be medics…and the results are predictable and consistently poor. I’m a HUGE fan of ALS first responder engines, but EMS is best delivered by people who want to be in EMS. If your department can straddle that line, jam on. If not, dedicated EMS is always in the public’s best interest, city, or county. My assumption of all the “fire-based EMS RULES” stuff is there is a competing private EMS system in play, and on that count Mr. Morse and I are in 100% lock-step.
Feel free to call me jackass all day man..I’ve been called worse today already
Scott, I hereby extend the proverbial olive branch…
We’re all in this together. My main point in writing the story was to showcase my appreciation of the firefighters in Providence. I did six years on an engine company and four on a truck before switching to full time EMS. I can always go back but I love my job. I think if you reread the post you will see that this had nothing to do with a patient abusing the system. The guy needed help, and we did a great job. There was no delay in treatment, I am very familiar with the patient and his employers who are concerned for an employee that has worked for them for twenty-five years. There was nothing cynical about any of it, it was a good call by all accounts, mine, the employers, the hospital and most importantly, the patient.
The blog itself is starting to get national attention, which is nice but was never my intent. If you have any questions about patient care and Fire/EMS in Providence, go back and read some of the posts from the last five years. I’m sure you could cherry pick things and write rebuttals but the spirit of the blog is a positive, learning journey. None of us are perfect.
That being said, as I mentioned earlier, these are bits and pieces of real events, genders, ages and locations are constantly changing.
I find this entire discussion interesting and I thought I would share my viewpoints on a few things.
1. Kidnapping – Whether Lt. Morse thought it or said it, I don’t feel that is what he did. He had a differential diagnosis in his head, but just because someone’s sugar is low, that does not mean that is the cause of their psychosis/combativeness/Altered Mental Status. I take no issue with him removing this patient from the scene and loading him into the truck.
2. Implied Consent – ABSOLUTELY! What would the prudent, well informed diabetic say when their sugar dropped for the third time in a month? “Wow.. I had better get this checked out!” Lt. Morse was acting in a manner of what he felt his well informed diabetic patient would like him to do.
3. Privacy – In order to maintain this patient’s dignity, do you think he’d want to be worked up in the middle of a dirty warehouse with all of his friends, colleagues, coworkers and supervisors watching him thrash around and fight with the Fire Department? Neither do I…. get him out of there!
4. Treatment En Route – With enough hands in the back of the truck, I don’t see any need to sit on scene and do everything right there. Get them going, treat them on the way to the hospital, and do not delay care. I dont think Lt. Morse delayed care, he just did things in a little different order than some may have. If, in your system, you say “Well, they’re unconscious .. we’d better work them up here.. they might wake up and not want to go” then I suggest you reevaluate your own protocols and drive to do this job. Above all else, DO NO HARM AND ACT IN YOUR PATIENT’S BEST INTEREST.”
5. A fire department based EMS system is the most effective way to deliver quality patient care to the community. – Slow down there, LT. I take issue with that statement.. SERIOUS issue. You say it better in the next sentence.. An EMS system staffed by trained and motivated individuals is the most effective way to deliver quality patient care to the community. Ask the residents of Detroit, Philly and Washington DC what their views of Fire Based EMS are.. they might disagree.
I am a 10 year Paramedic, and I have worked in Private EMS in a 911 system for my entire career, where I have progressed to a rank equivalent to yours. I think we do a pretty good job at providing EMS care to the community where I’m from. There are lots of other systems out there that would say the same about theirs as well.
The quality of care that is provided to the community should be measured by the quality of the provider, not by the color of the truck or the patch one wears on their shoulder.
Keep up the great work. I love reading what you write.
Scott Kier MASS EMT-P; B.S. EMSM
Thanks, Scott, much appreciated. The whole Fire based EMS thing was my feeble attempt to stimulates some discussion on the issue, then I realized I’m really not the person for that, nor is this blog the forum. I’ve always enjoyed the harmony here, and will strive to keep it that way in the future.
Wow Michael I think you have been slammed one too many times. Personally from a type 1 diabetics view I stand behind what you did 100% and as a medic oh yeah. If my blood sugar was that low and I was well not all there then by all means take me to the hospital and when I wake up if I want to sign out AMA then by all means but in the end you did what you knew was best for the patient. Good work man ohh and keep up with the “colorful writings” I love your blog it is great!
Type1medic
Thanks, Type 1 Medic, your comment sinks in far deeper than the others. I was hoping you would stop by as I was interested in your take on all of this, glad you did!
I guess this is a bit off-topic, but why did you decide not to use an anonymous identity when blogging? Most of the health profession blogs I come across use a pseudonym to protect themselves from having their blog posts used against them in real life.
I do realize that your blog posts are more a compilation of similar experiences than a factual account of a specific experience… but when one of your posts stirs up a controversy like this, doesn’t it worry you that people could take the story out of context and actually create trouble for you?
Robin
Four years so far no troubles! The administration at the PFD believes the blog promotes what we do for the city, I keep it positive and don’t get too many complaints. People like those who commented negatively here haven’t bothered to read the blog and get a feel for what its all about before commenting.
Plus, I’m trying to sell my book. Tough to do that anonymously
Ah ok, makes sense. Glad to hear the negative people go no farther than being used as an example of ‘what not to do’ by people who don’t see the difference between theory and common sense.