Something here is not quite right.

I'm sure you all know that feeling where things just aren't adding up and you can just tell that something about the situation is not quite right.  We get that quite often actually, and this recent call was no exception.

We were responding to a call for a man in his mid to late 60's who had fallen and possibly had a head injury.  This is pretty much the typical in my district so I really wasn't in the mindset of expecting what we actually got.  But from the moment we pulled up on scene it became apparent that this was not going to be typical.  As I pulled the engine up to the address I saw a young woman crouched in the driveway who appeared to be (or at least had been) crying and who was just staring out at the street.  I stopped the rig, turned off the lights, got out, opened the back door and grabbed some medical gear and she had not moved or spoken to us.  Tip #1 something is not quite right. We often get incorrect patient ages or genders on dispatch so my first thought was wondering if she was the injured party.  As I grabbed some additional gear from another compartment I called out to her, "What happened?".  She said, "I don't know".  Tip #2.  As we approached her she got up and started leading us around the back of the house to a small guest room addition in the backyard.  She stopped short of going in, pointed, and said what I thought was, "He's in the bedroom".  She didn't lead the way or go a step further.  Big Tip #3.  There was obviously something going on here besides an elderly slip and fall.

As I, cautiously, entered the room I looked around for where the bedroom might be and off to the side I saw, in the 'bathroom', my patient.  Much like my previous code blue, he was slumped on the floor having fallen forward from off the toilet with a pool of blood around his head.  He was not moving in the slightest and I knew right away what all those signs had been pointing to.  He was face down but it was obvious he was not breathing and when I touched him he was cool and had pronounced rigor mortis.  He had been there for awhile.  I notified the captain that this would be a coroners case and got out my monitor.  I documented that the patient was asystolic (flat line) in all three leads, covered the body, and marked a time of death.

My captain had had the same sense that things were off when we arrived and had stayed with the young woman which was a good thing because she was, rightfully, distraught.  We made the proper notifications and did our best to console the family, more had shown up by that time.  PD arrived and we turned the scene over to them and went home to do the paperwork.

Intuition is a pretty powerful thing and should probably be listened to a lot more than we do.  Fortunately there was no danger to us in this situation but it is a good lesson in paying attention to your environment, the people around you, and trusting your instincts.

I Hate Having To Do That

There is a very fine line between respecting a person's wishes and getting them the help they need. Sometimes it can be very difficult to walk that line, especially in our overly litigious society.

We recently responded for an elderly male who really put us to the test. Apparently he had been seen the night before for a possible stroke, refused service, and had been AMA'd by the ambulance crew. When we arrived, the family told us he had not been interacting with them as he usually does and after the episode the night before they were very concerned. Unfortunately the patient was very stubborn and was still refusing to be seen at the hospital.

There are only a few circumstances in which we can make a patients decision for them and send them to the hospital without their consent: if they are altered in any way, heavily intoxicated, or a danger to themselves (that is, wanting to hurt themselves). Our patient was able to answer all of our questions appropriately and was not drinking so that ruled out the first couple. However, he was not making decisions that were in his best self interest.

In addition to the possible stroke symptoms the night before and a pretty distinct one-sided weakness, he had a new onset irregular heart beat and rectal bleeding. He was not in major distress right now but he should really be seen at the hospital. We just couldn't force him to go. His family was very upset and pleading with him to go, but he wouldn't listen to any of us. We had spent the better part of a half hour trying to convince him and finally my captain told him that the decisions he was making were going to cause him harm. The patient said he understood, so the captain said, "So you do want to hurt yourself?" The patient said yes. He said yes in front of the ambulance crew and us, which is all we needed. We called the police to put him on a 5150 hold and allow us to take him to the hospital. It felt almost deceptive, like we tricked him with logic, but it was ultimately in his best interest. I just hate doing that.

I really feel that, for the most part, if someone wants to refuse service (even at the detriment of their health) they should have the right to do so. Unfortunately, that's not the world we live in; especially when so many have been sued by someone who refused help and then they or their family claim we should have done more.

Usually, when our patients are put in a situation where they have no choices left or have to choose the lesser of two evils, they cooperate. For example, patients who have a choice of going to jail or to the hospital, usually choose the hospital. Our patient was told that he was now going with the ambulance no matter what, so why wait for the police to come and fill out the paperwork? We could just get in the ambulance and go now. He still refused. He completely understood what was to happen and was stubborn enough to ride it out and make us jump through all the hoops.

I had been in and out of the room, talking to the patient and to the family and had missed some of the conversation. Somewhere along the way, my crew had been told that the patient had some weapons in the room. I didn't know this until the police arrived and said they wanted to clear the weapons before we proceeded. They ended up taking two pistols from the nightstand and a Rambo style commando knife from the dresser. I don't think he would have, or was in any condition to use them but I wish I'd known they were there.

After the paperwork was done, the patient got on the gurney and went to the hospital. The family was tearful and very grateful and understanding which made it a little easier. But, man, I still hate having to do that.