Further Notes On Yesterday’s Post

In an alternate dimension…

I find myself standing in front of the Coroner.

She says to me, “Did you consider that the patient who died may not have been competent to refuse transport? He was after all hypoglycaemic and septic. Why did you leave him at home instead of taking him to hospital?”

I reply, “Well our honour – I couldn't be sure. He knew what day it was, where he was and who was the prime minister. What I wasn't sure about was that he knew what would happen if he was left at home. *I* wasn't sure to be completely honest, there was something about him that I didn't like the look of, but I couldn't put my finger on it. I figured that he needed a doctor to give a full bill of health – not me.”

“So”, she asks me, “Don't you have capacity for consent tool for determining such things?”

“Yes Ma'am – but it's only really a guidance, it doesn't give us a checklist for things that we *feel* about a patient. It's very much a grey area and needs my judgement”.

“So, in your judgement”, she continues to ask, “Did you think that he was competent to refuse treatment?”

“I don't know – maybe he was 10% impaired – would that stand up in a court of law? I'm sure I could have filled in the competency either way, able to give consent, or not able to give consent. Either would have been a fudge”.

“And what do your guidelines say about people unable to give consent?”

“That I should use reasonable means to get the person to attend hospital – or get the police to assist me”.

“And why didn't that happen? Why did you leave him to die when you had such concerns about his health and some concern about his capacity to refuse treatment”. The coroner was asking me a lot of awkward questions.

“Well your honour – there are a lot of people out there who would rather err on the side of caution when it comes to consent. They would have us believe that everything is black and white and that we should always give people the benefit of the doubt when it comes to consent. After all it is only a matter of degree between telling a little white lie to someone to heading down the slippery slope of secret arrests in the night for people with communicable diseases”.

“So you left him at home.”

I gulped nervously, “Yes Ma'am”.

“To die?”, she raised an eyebrow.

“Well, I wasn't sure…”

“But he died didn't he?”

“Yes your honour”.

“You are a prat.”

I couldn't really argue with her, “Yes your honour – and I can't sleep at night”.

The coroner was unsympathetic, “Have you lost your job?”

“Yes your honour – the family complained and I was dropped like a hot potato. If I'd taken him into hospital then the family could complain and I'd have lost my job that way. But at least I'd be able to sleep at night.”

“And the patient would be alive?”

“Is that important your honour?”


Wow.

I go away for a few hours and return to comments either congratulating me, or saying that I should lose my job. (Because if there is one thing London needs right now is one less ambulance staff). Still its interesting to read people's thoughts.

Part of it though is that my use of the word 'fudged' was a bit ambiguous…

To be clear, the capacity for consent assessment could have gone either way, I could have had an officer and a few police down to try and persuade the patient (something I would have done if my bluff hadn't worked, I was *that* worried about him).

I wrote the last post partly to highlight that it's not always black and white as to what we should do in any situation. At 11pm on a Saturday night there are very few people around to help out. There is no psychiatrist to turn to in order to sort out a formal competency hearing. There is no form full of boxes to tick that take into account my 'feeling' of a situation – that feeing that you get which cant' be expressed in an examination box two inches deep.

You have to make decisions that will let you sleep at night – which often nicely tie up with decisions that are in the patient's best interests. You have only a limited amount of time to make those decisions.

Would it have been better to wait around for the patient to collapse again and then wheel him out while unconscious? Wouldn't that have been against his earlier wishes? Or did he not really believe that he would collapse again.

At the end of the day, the balance of probabilities is that he didn't know that he could become fatally ill – I wasn't sure that he would become ill again. So if I performed a formal capacity to refuse check (and when I get back to work I'll scan one in and show you the form), and it could have gone either way. Truly a grey area.

So I persuaded a patient by telling a vague mistruth – I can't 'medically arrest' him, but the police (along with a few hours of paperwork and mobile phone use) would be able to. He got the treatment that he needed, and he got it a lot quicker than he would have if I'd gone down the 'proper' route – which may not have worked anyway. The 'medical arrest' part was also just a small part of my attempts to persuade the patient to attend hospital.

At no point did I think that he wanted to die.

Here is the thing – If I go to someone who has taken an overdose that will be fatal without treatment, and they refuse hospital, know that they will die and are not confused – then I can't 'kidnap' them. If they are in a public place then the police can place them under a Section 136 and we can force them to hospital.

If they are in their own home then we are to leave them to die.

Then we will get a complaint from the family and we lose our jobs, are up before the coroner and most importantly have to try to live with what we have allowed to happen. And for most ambulance services you are guilty until proved innocent.

I'm a liberal type of person, but I also know that I have more experience of illness than 'civilians' – that puts me in the position of having more insight than a lot of my patients. Persuading someone to come into hospital to see someone with more knowledge than me seems pretty benign. I'm not going to strap someone down to get them to hospital. I'm not going to roam the streets and drug people and drag them off to be experimented on. I'm not going to drive around squirting fire extinguishers into smokers faces because it's 'for their own good'.

What I will be doing is the best I can for people – so that I can sleep at night knowing that I helped them out.

…Until I read comments that make me ill with worry that I'm some sort of monster who shouldn't be allowed near children or something – seems I'm a sensitive soul after all. And that is nothing compared to the abuse that I get on the job.


This post was written after a few pints. I hope it doesn't read like a horrible mess when I look at it in the morning. I still think that calls for me to lose my job are a shade on the harsh side though – although if I wasn't an ambulance worker I would have a longer lifespan, relationships that might work, better health and possibly a job that pays me a lot more than £10 an hour.

Actually… anyone want to hire me?

My brother goes into hospital tomorrow to have some teeth chiselled out of his jaw under a general anaesthetic – so I'll be unreachable for much of the day. Please continue to argue in the comments box.

69 thoughts on “Further Notes On Yesterday’s Post”

  1. On the manslaughter question it's a difficult one. On a strict intepretation of the law the prosecution would have to show that Tom's failure to treat the patient was negligent and that the negligence was gross.By attending the patient Tom has undertaken to care for them and thus owes them a duty of care. Tom then has to discharge that duty of care by meeting the standard of care of the reasonably competent paramedic (more on how we decide this later). Let us say that Tom's initial treatment was textbook. In theory the matter should end there as Tom would have discharged his duty of care.

    But what if Tom had decided to ignore his instincts, left the patient and the patient died? That's a slightly greyer area. The question would arise what the extent of Tom's duty of care was – i.e. was he under a duty to ensure the patient recovered fully (I can't answer that) – and whether, by leaving the patient, Tom had acted in accordance with a practice accepted as proper by a responsible body of paramedics. Given the feedback I've seen on this blog so far, I think that may prove problematic. The finer points of the law can be argued to the nth degree, but this gives you something to start thinking about.

    On the suicide issue the law is clear. If a patient dies as a result of a healthcare professional accepting their refusal of treatment, this does not amount to assisted suicide.

  2. I'd err on the side of potentially saving a life. If you were wrong a live patient can sue you a dead one can't. When I teach medical students about capacity I remind them that the world is not an environment where there are any true absolutes, only relative truths. You have first and foremost a duty to a patient. Perhaps you should have followed the letter of the law and used the police to transport him but ultimately your approach was the more compassionate. I'd have one individual who took your approach to a dozen who look out for their own backs or are inflexible in their management strategies. I'd be happy for someone with your values to scoop and run with me or mine.

  3. Don't beat yourself up. Anyone who has ever done this job knows that there are times when things just don't fit neatly into the rule book, and a big part of our job is being able to think on our feet. If we couldn't, we'd all be ineffective robots and then where would we be ? Have another pint and don't listen to the naysayers.

  4. As I read your first posting on this and the subsequent responses, I tried to put myself in that situation. I have been a medic based in a trauma unit, I have taught well over 100 students to be medics and I've personally spent hundreds of hours riding “on the streets”. Had one of my students told me they did what you described, I would have explained why we don't lie to patients, why there are laws to protect people's rights to refuse treatment and suggest they consider the consequences of their actions in the future. Then I would have patted them on the back and told them they did the right thing. Sometimes it's just that, the right thing to do.As a caveat, I was sitting here smugly thinking how I have never lied to a patient. Then after thinking for just a few moments, I realized it probably wasn't as uncommon as I thought and wiped the smug look off my face.

  5. How anyone can criticise what you did is beyond me. So you lied to somebody, big deal. You saved their life – what's more important than that? It's the people that insist upon the execution of the absolute letter of the law that are the fascists in this debate.

  6. For what it's worth Tom, I know I feel you did the right thing. It may not have been the politically correct thing, and no doubt someone will be along to point out NHS guideline this, or policy that (since when did Guideline come to mean Rule in this strange society?), but you were the one at the coalface, making the choices.My advice: Ignore the idiots and relax in the knowledge that you saved a life.

  7. I am utterly amazed that anyone could react negatively to what you did. Would they seriously prefer that you'd left the man to die, rather than tell a little white lie to persuade him to go to hospital?I refuse to believe that anyone hasn't told a lie of similar magnitude at some point in their lives. Hell, I've told far larger whoppers to my daughter just to get her to behave or eat her food or whatever. (e.g. no, a policeman will not come and arrest her if she doesn't stop yelling and running around – and how about the proverbial “if you don't shut up I'll turn the car around”?)

  8. What angers me is that you have been put in a position where you feel you have to justify saving a life.You made a good call.

  9. Abso-frickin'-lutely.It's scary people think the rules are more important than saving that man's life – he wasn't suicidal it seems, he didn't actively want to die.

    If he did, then going by the post he'd be eligible to be sectioned anyway.

  10. As I'm sure you know, the law clearly states that all patients are to be deemed competent in the absence of absolute evidence to the contrary. So any indecision or close-to-the-wire patients have to be assumed to be competent.Having said that, I doubt your patient was competent, according to the law anyway, in that I'll bet that while they could repeat what you've said to them, they didn't believe it. If you can demonstrate that that was the case, then yes, by all means, take them to hospital.Just don't EVER lie, deceieve or trick someone. Patients are vulnerable, especially in emergency situations, and lies breed contempt when you are discovered, and mean that this patient is going to be less likely to trust a healthcare professional in the future. And then how would you go about saving their life?

  11. Probably, there are others who have done this before, and others will do it later, but you posted it on the web and therefore have to justify it…The times change. A few years ago, I think people listened more to medical advice. Or else, they had family around that could either persuade them to go to hospital, or look after them if they didn't – at least to a larger degree than they do today.

    I don't understand why so much responsibility sits on the shoulders of ambulance workers. While it seems you are getting better and better training, it is still doctors who should have the life-and-death-responsibility (that's what they (we) get paid for, isnt' it? some of it, at least). Of course, everyone needs to be responsible in their jobs, but you shouldn't walk around with the fear of being sued for the things you do.

    (on a sidenote: The americanisation of the health system saddens me, the fear of being dragged to court makes us do a lot that we really don't need to do except to “cover all eventualities”. It is bad medicine and expensive.)

  12. “…this patient is going to be less likely to trust a healthcare professional in the future.”That'll be the future he has at all because Tom lied to him.

    Perhaps a small point, but nonetheless one worth making.

  13. And what of the other people around, all potential future patients, who also observed that this patient was conned?There is a perception in society that healthcare professionals (in tandem with other public sector workers) cannot be trusted. This only reinforces that viewpoint.

  14. I have to say that I'm not impressed with the people calling for you to lose your job.”The health of my patient will be my first consideration” – Current version of the Declaration of GenevaWhat would these people who objected do, if faced with someone they thought would die? More to the point, they had been called to assist this person – that gives them literal and moral responsibility in the event of that persons death.It really comes down to whether or not the person was qualified to make the decision, and I would say on the balance of what you've reported that they weren't. They had expressed no direct desire to die, and yet they believed that the best course of action was not to be treated – but having said that, they were still recovering from unconsciousness and could reasonably be believed to not be totally mentally competent for this reason.Some of these lynch-mob commentators would be the first in line to condemn you if you'd left the patient and the patient had subsequently died. Most would probably condemn you if you'd got the police involved but the delay that would inevitably cause had cost him his life. A term has been coined in American politics: the 151st Keyboardists, the group of people who can make these decisions right 100% of these times from behind a keyboard, and hold people to judgement if they decide something different.Don't let them get you down.I remember on an episode of “Car Wars” a police officer suddenly deciding to pull over a car because 'something wasn't right'. She couldn't say exactly what that something was, either at the time or afterwards – but it turned out to be completely accurate… the car had been stolen, but not reported as such at the time.My point is, when you've been in the job for a time, you develop instincts. Instincts that cannot be easily explained, but often prove to be right. In this case, you followed your instincts and doing so probably saved this patients life where not doing so would have cost it.You made the right decision. You may not have pleased the 151st Keyboardists, but you saved a life, and that's your job.Good call, Tom

  15. But, parallel universe, how would they have felt if he'd died later: they'd seen the ambo called, seen him treated, watched the ambo drive away…. and later he conks it, and they find out it was because he wasn't taken in?That'd surely lead them to think EMTs are negligent and/or don't care about people in hostels….

  16. > You saved their life – what's more important than that?A lot I'd say. Liberty and freedom are rather important. Lots would agree – that's why many are willing to lay down their lives in wars.

  17. Make up your mind, numbers.Since when did not believing someone provide 'absolute evidence of incompetence'?

    You sound more than a little confused yourself!

    If you 'doubt your patient was competent , according to the law'

    And 'the law clearly states that all patients are to be deemed competent in the absence of absolute evidence to the contrary'

    So just not believing what you're told makes you crazy?

    It must be nice to have such a nice, comfortable, black & white world to live in. Enjoy it while you can.

    As for 'contempt' and trusting ambulance crews, I believe that the patient themselves and any onlookers would more likely think:

    “That man just saved a life.”

    I can't say they're more likely to trust 'healthcare professionals', because some of them might think like you do.

  18. Well I think like most you acted correctly. That said, this post and replies is absolutely brilliant as a case study and should be used as a good debating/training discussion document for many people and professions, if only to drive the point home.In particular, because of its content, politicians, legal eagles, medical professionals and Trust Management should ALL be forced to read the document in full.

    At the end of the day it shows how society today has lost the rule of common sense and tangled itself up in a web of beaurocracy, cotton wool, confilicting rules and legalities. What a shame, a big bad shame. The trouble is, it will only get worse, guaranteed.

  19. Well I think like most you acted correctly. That said, this post and replies is absolutely brilliant as a case study and should be used as a good debating/training discussion document for many people and professions, if only to drive the point home.In particular, because of its content, politicians, legal eagles, medical professionals and Trust Management should ALL be forced to read the document in full.

    At the end of the day it shows how society today has lost the rule of common sense and tangled itself up in a web of beaurocracy, cotton wool, confilicting rules and legalities. What a shame, a big bad shame. The trouble is, it will only get worse, guaranteed.

  20. It's hard to be free when you're dead. Saving the patients life was the right action, and I strongly suspect when the dust settles the patient will agree.

  21. Speak for yourself. I for one trust healthcare professionals to do their best for my health unless they prove to me personally that they are incompetent.I don't consider NHS workers saintly or flawless – I wouldn't, for instance, accept a lift home from the guy in the pub just because he's a doctor, or lend 50 to a stranger just because they're a nurse – but on a professional level, I trust them to do what is best for me in any given situation.

    Don't try and transpose your own insecurity and paranoia onto the whole of society.

  22. I agree with this.We have rules and we have the rules for a reason, but occasionally there will be a situation where rules like “preserving human life” override all others.

    Example: as a rule it's not right to forcibly break into someone's house and abduct the children from their beds, while smothering them in blankets.

    However, if the house is on fire, it's exactly the right thing to do.

  23. I hear you, but from what I've read so far, it wasn't like the man was refusing to go for any kind of principled reason, or refusing all treatment for religious or ethical reasons, whatever – he'd received treatment already and simply didn't want to go. Hardly a case where his liberty and freedom were under threat, more like a disagreement over the best course of action.

  24. I completely agree with this post. I teach medical law (amongst other things) for a living and as I was reading through the whole debate I was surprised at how polarised people were in their viewpoints and thought how useful this scenario would be for use in a tutorial on consent and capacity.Whilst there is room for arguing that Tom breached the law on a strict application (and I am not saying that he did or didn't), there is also a need to be sensible about this.

    The law is not completely inflexible, nor are judges inhuman. I am relatively confident that if this case was to appear in a court of law the judges would pat Tom on the back and throw the case out. At the end of the day an individual's life was saved and I've not come across a case yet – although the very nature of blogs means that someone will know of case – where an individual has been resuscitated (possibly in contravention of a DNAR order which the ambulance crew were unaware of) who then sued the Ambulance service for their troubles.

    Don't get me wrong, I believe in the importance of individual autonomy and the need to let fully capable patients make decisions about what treatment they do or do not agree to, but reflecting on Tom's situation I think there are a number of things to take into account:

    1) It is easy for anyone who wasn't immediately involved in the situation (and lawyers are particularly guilty of this) to pick through the aftermath of a medical decision with the benefit of hindsight and to question every aspect of the defendant's judgment, but decision making in medical practice does not work like that, you don't have the time to sit back, reflect on the ideal course of action and then act. Delays often cost lives;

    2) The law requires an individual to be able to weigh up have an understanding of both the information they are being presented with and the consequences of their decision. Where the consequences of their decision will necessarily be death, the law will expect a higher standard. There seemed nothing to me in the facts presented in Tom's blog which suggested that the patient was actively refusing treatment because they wanted to die. If push came to shove I would suggest that, since the consequences of their decision would have most likely have been death, this would lead me to believe that the individual did not really have the capacity to refuse and Tom was free to treat them in accordance with what he believed to be in that individual's best interests.

    3) Tom freely admits that he deceived the patient in order to obtain their consent. Consent obtained by fraud is generally not valid consent, however, in all the cases I have come across where this point has been made the motivation behind the deception had some crinminal element (e.g. deceiving dental patients into consenting to unnecessary treatment in order to boost profits). Regardless of the means used to obtain the patients consent, Tom's motivation here was surely a noble one and I don't believe he would be condemned in the courts for it.

    4) I have seen the point made in another posting that guidelines are not the same things as rules. This observation is spot on. Never lose sight of the fact that guidelines cannot possibly cover all circumstances and also that, whilst a failure to adhere to guidelines mey be indicative of a breach of the duty of care owed, a slavish adherence to guidelines when thecourse of action recommended by them was not best suited to the situation is just as bad.

    I for one would like to think that if I was in the same situation as Tom I would take the same course of action. Likewise I would also like to think that if I was in the same situation as that patient that someone would take the same course of action with me as Tom did.

    Whether my post takes the debate anyfurther or not is another matter, but I await replies with interest.

  25. What ever happened to the primary rule of 'First Do No Harm'. Keeping the patient's best interests in mind at all times will always steer you in the right direction. It would be one thing if Tom lied to the patient in order to perform an invasive procedure that may have had a negative outcome, but telling a small mistruth merely to TRANSPORT the patient to somewhere where definitive diagnostics are available seems to be a no brainer. What could the patient possibly sue for anyway ? Illegal transportation ?It would seem to me that in any such case, the two most important factors are the outcome of the patient and the intent of the deception. If you can clearly expect that the patient outcome will be radically different (i.e life vs death), and your intent in 'persuading' the patient through a small deception is purely their own well being – then I'd say your conscience is clear.

    As we all know, failure to act or patient abandonment is also a punishable offense, so in some respects you are damned if you do and damned if you don't. Out there in the real world, there's some kind of improvisation that occurs on almost every call. People who would be critical of Tom's actions must have never stood in his shoes.

  26. My father was sent for 'unnecessary' tests after a Doctor had a feeling that something 'wasn't quite right' with him, despite the first round of tests revealing nothing. He just believed that my father's unexplained fatigue was something serious. He was right. My dad had a 99% blockage in an artery that, if left un-bypassed, would have resulted in his being dead before he hit the floor from a heart attack. I still have my dad because of someone's instinct and willingness to do what he thought best, protocols bedamned. I'll defend that sort of choice all day long.

  27. Medical professionals lie on a daily basis to their patients – most of them are little white lies:”This won't hurt a bit”

    “You'll feel a little discomfort”

    “A mammogram is pain-free – you may feel a bit of a pinch”

    “Ah, I've got a good vein here”

    I could understand perhaps if Tom worked in the US – where medical care is NOT funded by the government, and where a short hospital visit can concievably cost more than an average home mortgage, that folks would support rejecting transport to hospital. I don't entirely understand this in the UK.

    If I'm ever over there – and drop down and refuse transport – please lie to me, k?

  28. Tom, you did exactly what was needed, you have NOTHING to berate yourself for. It sounds as though the incident really disturbed you. I hope that you can put it down to experience soon though you were definitely between the devil and the deep blue sea.About people who overdose I have very ambivalent views and feelings undoubtedly because I have major depressive illness and feel condemned to stay alive because of what it would do to others if I didn't. I can also understand how terrible it must feel to leave someone who is going to die when your whole being rebels against that. What does the law say about it? Would you be complicit in suicide or manslaughter if you left someone rather than getting them sectioned? Of course you couldn't know how long they had been ill or what they and their Drs felt the prognosis was. Sometimes nothing can help make life reasonable or bearable. Patients who have had both say that depression is worse than cancer, heart attack, trigeminal neuralgia or kidney stones because there is NO hope. The whole thing is so horribly tangled.

    Take care of yourself,

    Isobel

  29. I'm going to reply, to myself, because I missed something: I wrote:”parallel universe, how would they have felt if he'd died later”

    I should have written:

    “parallel universe, how would they have felt WHEN he died later”

    I'd also like to add that if this case is the biggest injustice you've met and that you have time and energy to spare addressing, then you obviously don't watch the news much.

    Or know for example that fluoridation of the water supply in selected British areas is the most grotesque example of medication without consent imaginable – go google “china iq fluoridation” or “bone cancer fluoridation” and then you can really have some fun.

  30. I've studied a bit of law (though not as seriously or professionally as you, of course!) and a lot of what I learned depended upon what was “reasonable” – and, perhaps more importantly, the judgement of what a “reasonable” person would know, do or behave like in any given situation.Tom's behaviour meets that criteria 100% in my view.

  31. If I am ill I would like to be treated by a caring and thinking human being – not a rule bound automaton.Your common sense and your ability to bend the rules when it makes sense are both appreciated.Your honesty and bravery in admitting when you do have to bend the rules are also admirable. I hope none of the jobsworths manage to use your honesty to make life difficult for you.Taking responsibility is often difficult and fraught with pitfalls. Just following the rules is easier – but sometimes makes less sense & is less effectiive.Well done. Thank you.

  32. On the plus side, you acted with common sense and compassion. In response to the critics, I'd say that if a person really does want to be left to die, then at least s/he could try again later; whereas if they are left to die but weren't actually that keen on the idea…well, you're buggered.On the downside, I think you used 'alternate' when you meant 'alternative'.

  33. Dilemma?In the days when Pace makers be external [internal ones, 2 speed sex , no sex ] and defribrillators could unload 500 Joules of energy on to the T Wave.

    I witnessed a situation in a CCU of 14 Beds one Sunday afternoon. I was there on emergency to return a Monitor with all the bells and whistles back to a working condition. In the bed opposite to my working position, a Patient flat lined, setting off the alarms and causing a crash cart to be moved, quickly to the location accompanied by Doctor and Nurses. the Doctor quickly had the patient s heart beating and the patient was fully comos mentos in a heart beart, when he let forth a string of juicy cuss words unfit for my tender ears along with the statement l****************let me die you**********************, Of course, they carried on with the treatment.

    The debate be was he lucid?

    Then the cost of the bed be only 20 times my weekly wage per day.

    I did not stay around long enough to see the long term result.

    Of course now I have a legal paper in my wallet stating to effect that I want no unusual treatment to keep me functioning, daisies need food too, as I be in that stage of life that the Bard says 'sans eyes , sans teeth , sans taste, sans everything.'

  34. I think, that despite all the medical knowledge, education, training, protocols, forms etc etc etc etc someone has, that..gut feeling, perception, even a 6th sence can help in a tricky situation.

    Sometimes you know that something is wrong but can't quite put a finger on it but you do something that had a positive outcome for the patient (or that situation if it is in general day to day life).

    Sometimes it then needs some lateral thinking ( bending the rules!) to get out of that situation to ensure that the person gets the best possible chance of living.

    Tom, I admire you for posting the message about what happened. other posters have said that they may have lied to get the patients to comply – for their benefit!

    I know too well that doctors tell a wee white lie when trying to get a venflon in me ' just a small scratch' ! (My veins have usually seen them coming 2 minutes ago and have shut down!)

    Take care Tom!

    Kate

  35. So Tom is the enemy of liberty & freedom because he did the right thing, the courageous thing? You're a complete loon. If war has taught us anything it's that the right thing to do is to follow your own conscience. Take the Kiwi soldier that won a VC last week, for saving a mate's life in Afghanistan. I wonder where he'd tell you to stick your regulations?

  36. On a different note, best wishes for your brother tomorrow. I was recently a victim of the back teeth thieves, and it's more painful than it might first appear 🙁

  37. Your name seems to indicate why the teeth had to go. I suspect that had your name been Mr Celery, all would have been well…

  38. I was going to write a really long piece about this, but I am not now. I have been thinking for most of the day about this, we have read most peoples comments and ideas, but it is interesting that those who are calling for TR's job, have missed the very obvious and I think very clever thing that Tom did in this situation. Everyone is saying how this person was mentally competent, or not. Yet if you read the post very carefully Tom says that he called the guys bluff by inventing “medical arrest”Now any mentally competent person would indeed notice this rather big “bluff” and see through it. So surely all that Tom did was carry out a rather interesting mental capacity test, which the patient failed.

    Might be a simple view, but I can't see anything wrong with that. Well done Tom, I don't think anyone else would have thought up that test even if you asked them to.

  39. I can't comment as a medically trained person, or even someone who has been in your paitents situation. As a human being I can say I'd far rather i'd been told a little lie and my life been saved, then been left to die. Isn't that what your job is about? Being human? Both you and those you are sent to treat?God forbid my little boy(and there is nothing more precious to me than him) ever needs emergency life saving help, then I hope that is someone just like you that is sent. Someone with the wisdom and humanity to just do the right thing and sod “protocol”.

  40. Just want to say again, well done tom. I'm just glad there are people like you who are willing to use some common sense and do what you thought was the in the patients best interest at the time.Sadly now you can't tell folk they're being idiots thesedays as you'd likley end up with a court summons at your door.

  41. In the post, Tom said multiple times that this wasn't a black and white issue, interesting then how almost all the comments have fallen into two very clear and opposite sides of the argument. I'm very good at greys, so I'll see if I can introduce some.First of all, Tom should NOT lose his job. Categorically, absolutely not.

    It seems to me there were options available,

    (a)lie to the patient to get him to hospital and save his life

    (b)declare him metally incompetent and take him to hospital and save his life.

    It seems (b) would be the most ethical and adequate solution to the problem, surely nobody thinks lying to a vulnerable, ill person is a good thing to do. From what Tom has written it seems everyone agrees that it is extremely likely that the patient was incompetent, so this was a viable course of action.

    However, I have no idea of what is actually involved in terms of logistics and time for option (b), I would love to see the form Tom mentioned.

    Lying was not the best thing to do, but is excusable, and I have no idea what I would have done, having never been in any comparable situations.

    If I was the patient, I would like to think where given the option of staying home and probably dying or going to hospital, almost certainly living, then I would always choose to go to hospital.

    It is possible the patient has a phobia of hospitals or has had bad experiences in hospitals, and would never opt to go to hospital, unless he could actually see himself bleeding to death or something.

    Most sensible people would place no major fault at Tom's door, but is important to realise that ethically and morally (and maybe even legally) there were better and more correct options.

    Should he have tried harder to persuade him? Should he have declared him incompetent and forced him? If these were possible then unequivocally yes. The question is then, were these possible? I will bow to Tom's superior judgement.

  42. If what Tom did was ethically, morally and legally debased then he wouldn't have received any support at all. As has been pointed out, Judges are human too and regardless of a technical legal breach it is inconceivable that he would ever face legal sanction. I think that it's appalling that you invoke ethics and morality as justifications for letting a man die (just as others have invoked liberty and freedom for the same reasons). No I'm not misreading you, I just find your miserly support somewhat distasteful.

  43. bloody hell you can't do right for doing wrong can you! I hope that if ever I am in a situation where I need someone to do what is best for me (save my life, talk some sense, realise I am sicker that I think I am, get me the help I need, ignore the rules if needs be,and think of me as a human being not just a tick box, ethical, moral dilemma) then I hope you are the one that I get when the ambulance arrives.

  44. Justification for letting the man die???Note I presented two options, none of which involved anyone dying. I invoked ethics and morality as justification of not lying to somebody, what is wrong with that?

    I never said he would or should face legal sanction, and I only said that it may be possible that what he did was against the law, I would never say an action was “legally debased” when I don't know the relevant laws.

    “No I'm not misreading you” Well, you do a good job of giving that impression. genau, you have created a excellent straw man, but arguing against a position which isn't present may not get you far.

  45. Tom,Regardless of what anyone says, or the legal niceties of the guidelines – YOU did the RIGHT thing. Your instinct and experience kicked in and you made sure that a seriously ill patient was taken into medical care. Whether the patient took the OD on purpose or by accident or was suffering from an adverse side affect to the medication doesn't matter, whether he was capable of refusing to go to hospital or refusing medical treatment, doesn't matter – as a medical professional your first duty is the preservation of human life and to ensure patients are treated with dignity. YOU did everything that is expected of you from an ethical standpoint and to bollocks with the legalities.

    If I'm ever in a situation where I need emergency medical care, I would hope that the paramedic attending me has the same sense of duty of care that you do.

    PS. Nice one with the “medical arrest” bluff – that's called thinking on your feet.

  46. Hey, no need for massive generalisations and personal attacks. I merely made the point that for some people their principles are more important than their life.Sometimes the most courageous thing is to realise that you don't agree, but you will support their viewpoint anyway. To use the oft-quoted, and possibly over used:

    “I disapprove of what you say, but I will defend to the death your right to say it.”

    Evelyn Beatrice Hall

    Every situation is different, and must be managed differently. Just like you shouldn't give up on a clearly incapacitated patient, you also shouldn't force clearly minded individuals to undergo procedures they don't want.

    Personally, I think Tom walked a slippery slope, but managed to stay on track. He has realised that this is a tricky situation; one that requires care and thought.

  47. I'm a potential future patient – and I bet I'm not alone in feeling that I'm more likely, not less likely, to trust healthcare professionals because of what I know happened here.Tom did exactly the right thing, and if it had been me in the back of his ambulance, I'd be exceptionally grateful.

  48. “It seems to me there were options available,(a)lie to the patient to get him to hospital and save his life

    (b)declare him metally incompetent and take him to hospital and save his life.”

    But what would be the long term implications for the man of having been declared mentally incompetant?

    There's a slim chance if he's in a hostel and wishes to be homed in social housing at any point, that it may increase his chances, by increasing his “points” which often relate to how vulnerable the person is: but it may also have negative repercussions should the man seek a job and find that his employers wish to check his medical records.

    Personally I'd rather be lied to than have permanent records stating that I was once declared mentally incompetant follow me around for the rest of my life.

  49. I sometimes wish “medical arrest” existed, when seriously ill and INFECTIOUS people show up for work just to score Brownie points, and show what conscientious, eager little beavers they are…. (JK!)

  50. Just to say, Striken, time is against you on option (b) which is why (a) was chosen.Last year i was starting the (b)-esque option of removal to a place of safety on someone. Fortunately, my buddy persuaded the patient that we should move her for her health and her life. There was nothing illegal and everything ethical.

    If we'd had to pursue the (b) option the patient might well have died by the time the paperwork and people involved in such paperwork would've arrived.

    The same, as i see it, may be said of Tom's patient.

    If there were bets to be laid, i'd put money on his patient not even remembering what had happened and what was said. When people have had a severe MI/cardiac episode you see how many remember what happened? yet they talk as if they know what's going on.

    Tom put medical skills, judgement and experience together and made a call. IMO, it was right.

    There are always OPTIONS but very few are genuinely feasible.

    All the best

  51. Tom, if you're reading – a question:Given that there was some question as to his competence, and some question as to his wellness, why did you invent 'Medical Arrest', rather than tell him that you weren't sure he was OK and that if he didn't get in the van you would get the police to help you get him in the van? Which wouldn't have been a lie, but which may have had the same effect.

    It seems to me that rather than truly lying, you were using 'Medical Arrest' as shorthand for 'going through the process of deeming him unfit to consent.'

  52. I had no idea that people in your profession had to leave a patient to die if they dont want the help and are all those things you said. How hard it must be, this makes me respect you guys even more. It is a sad situation, but I guess that if that is how someone genuinely feels, then it is no-ones place to tell them to survive if they really dont want to. It is a hard call to make, but there always has to be a point where we just have to back off because we cant control others' lives. We just have to do the best we can and hope that it is the right decision for the patient and for the EMT/paramedic.Big respect to you and the rest of you guys!!

  53. I have been in the Coroners court twice due to people refusing to travel and then dying. The first one was a woman who would not travel even though I told her that she was unwell and might die.Her partner accused me of being “uncaring” and said it was my fault that she died because I did not drag her into my FRV.The second time was three weeks ago, the lady had mental health issues and refused to travel. I had been to her previously and spent over an hour with her before she agreed to go to hospital.In my experience , if you do your best and DOCUMENT everything you have done, you will not be in any way to blame. I must say though, jobs like that make me feel like shit, all I want is for people to be O.K

  54. Cheers, EmT. Like I said I don't know what is involved in (b) and how quickly the patient needed to get to hospital, because I am not a medical professional and I wasn't present.So, as far as anyone who wasn't thee can say, Tom made a good decision from the patient, which is ultimately his job. Saying that, it was far from an ideal decision, which probably doesn't exist.

  55. It isn't Tom's job to weigh up the consequences of declaring somebody incompetent, just to make a professional judgement on the mental state of the patient. If he had to consider all the possible consequences of every medical decision he had to make, nothing would get done. (which incidentally makes this discussion, albeit very interesting, pretty much pointless)Again my lack of knowledge is appalling, is a temporary lack of competency due to a medical condition count as a mental illness? Would it actually go on his medical records?

  56. It all boils down to intention (something which is missing in today's society). In batsgirl's first example, the intention is to abduct the children. In the second example, the intention is to save their life. The two may involve the same action, butthey should be treated totally differently.

  57. We must also accept that this is the age of compensation. Yes, it is ABSOLUTELY the right thing to save someones life when they will die, even if you step on their toes slightly. However they may see the opportunity for a quick buck.About a year ago I saw a middle-aged woman just collapse in the street with no pulse or breating. I have no clue on diagnosis so i started CPR (trained in such) and called an ambulance. Crew arrives, I give signs/symptoms/history and off they go.

    A few months later I get a court summons, because she is sueing me for cracking her rib and inflicting “severe emotional damage”

    If I wasn't so flabbergasted and old-fashioned…i'd have hit her and given her a real reason to sue.

    Thankfully the case collapsed and the woman looked a right prat, but the fact that someone who would have died, would even consider sueing her rescuer, has eroded my faith in humanity slightly.

  58. My husband's a diabetic and I've nursed him back when his blood sugar was so low the meter wouldn't read it. When his sugar first returned to a normal range, he was alert, articulate, comprehensible, and frankly, out of his mind (even he admits this afterwards). Truthfully, he did not even remember the conversation fifteen minutes later. He would have argued with you too, but I sincerely hope that any paramedic treating him would do just what you did. I'm kind of attached to the guy. It can take hours for the mind to come fully back online after an episode like the one you've described. Thank god you were there. We need people like you who can see the whole situation and act based on what's best for the patient. I believe that everyone has the right make their own medical decisions, but there really are times when we have to look out for each other's best interests. The best thing is to approach each case individually, with compassion, and know when the situation might require an answer that isn't next to the checkbox on the form. You did well.

  59. I hate to disappoint all you guys out there, but….. wait for it……horror of horrors……we lie to you every single day.For example…………from patient who has knob stuck in bottle……….”You must think I'm completely stupid?”……….Me: “No, not at all……we see things much worse than this”

    Or, from wee girlie who's had a frightening amount of alcohol……….”You do believe me don't you, I have only had two drinks tonight……and my drink was definitely spiked……”……..Me: “Of course, don't you worry now……..now if you'd kindly vomit in the bag next time that'd be great”

    Or from aged abandoned patient with no family to give a damn and who's had no home care because some nameless, faceless number (sound familiar 24601?) decided it was ok to let them refuse home care, but is now welded to their chair with urine, faeces and discharge from chemical burns from their excrement………”I'm sorry, I must smell dreadful, this must be terrible for you”………Me:”Not at all, don't you worry, its not a problem to us at all, that's what we're here for”

    Oh, and by the way, I've been to those patients, (I cried over the last one when I came off shift next morning, and again that night when I discovered he'd died.), and no, the last one is neither rare or unusual. He was finally discovered when a neighbour complained about the smell. Thank god for our ability to lie and be insincere convincingly. Its critical to our patient care.

  60. The more I read from you the more I worry. If you are really what you say you are and not just a fantasist enjoying all the attention, I wonder how many of your patients have made decisions, believing themselves to have been making informed decisions when your biased dogmatic inflexible opinions loosely based on your perception of fact are the source of their information.What is it that happened in your past that makes you so passionately fight your corner? As I have speculated before, did you once leave a patient to die and now feel forced to defend your position so irrationally to justify whayever you did at the time? I guess you don't sleep well at night.

  61. Wonder how long all the forms etc would have taken for Option b? Maybe by the time that had been done he'd be dead anyway?

  62. I'm in the US, where laws are different. I've been in some pretty hairy refusal situations, too. And let it be known that the smart money is on transporting a patient against his will, no matter how competent, than to let a patient refuse and later die.Competency be damned. What refusals in court always come down to is, “Did the patient have enough information to make an informed decision?” On my narrative portion of my run tickets, I can fit about three paragraphs. Can I in three paragraphs fit an entire description of every possible statement made to convince a person to seek treatment, AND write all other necessary information? NO.

    I have transported people oriented and alert against their will. I just did it last night. I won't take that chance about a refusal. I had a guy who was stabbed in the chest, right over his heart, try and refuse. I didn't give him an option. I simply said, “Going home isn't an option. Here's the closest three hospitals. Which one will you go to? Leaving isn't an option. And neither is driving your car.”

    I don't ask people IF they want to go, but which hospital they want to go to. Anything you can do as a paramedic to minimize refusals is going to save your ass. You might have someone complain that you took them against their will. But that's a complaint. If someone DIES because you did a refusal, you're going to be in a world of shit, jobless, and probably never work as a paramedic again.

    What's the safest thing, and the thing in the best interest of a patient? Transport. Always transport. If someone absolutely refuses, it takes twice as much documentation and time to ensure you went well out of your way. It takes forever to go through the whole list of possible negative outcomes, ensure that the patient understands it, and still I feel a little uneasyness about it.

    You won't get sued or dragged into court because you transported. But let a patient refuse and that risk goes up dramatically.

    I don't care if a critical patient says, “I'll go with you, but don't touch me, don't poke me, and don't talk to me.” Fine. Get in. I won't even do a blood pressure. But at least I transported. I can live with that.

    I've have friends and coworkers who got into a world of shit over refusals. One crew had a patient who was severely injured. He refused care. Per protocol, the patient was oriented, alert, and competent to refuse. He died a few hours later. Who do you think got blamed? It wasn't the patient. It was the crew.

    If they tried being nice, tried talking him into going, tried persuading him, tried threatening him, and it still didn't work, so they finally just dragged him screaming to the truck, nobody would have faulted them for it. But because they were too hung up on the whole “competent to refuse” they got into a heap of trouble.

    That call sticks in my mind, and it changed how I operate. I'm very aggressive about getting patients to the hospital by any crook or hook I can find. I've had patients with life threatening arrythmias refuse transport. It took me scaring them to the point of tears in fear of their life, sobbing and babbling like a baby, before they'd go. And I don't feel the least bit bad about it because the fact is, they SHOULD be in fear of their life. It was at stake. They simply didn't understand the gravity of that situation.

    When you're called in to court about a case of patient refusals, it will come up that you, the paramedic, are medically trained to recognize life-threatening situations. The patient is not. YOU had the duty to exhaust every option, every avenue, and transport. Falling short, and having a patient die, will never be excused.

    As for the court cases or disciplinary actions for transporting a patient against his will? You won't find very many. No attorney is going to sue a service or a provider for transport. But you will find them suing you for lack of it.

    Like the post says, I do what it takes so I can sleep at night. If I go home at the end of a shift and wonder, “Did I do the right thing with that refusal?” Then I know I didn't. You should never wonder about something like that. If you find yourself wondering how the patient fared, you screwed up.

  63. I can't vouch for other people, but I have seen people who are shot, as in with a gun, refuse care and transport. People who are stabbed or bleeding profusely vehemently refuse care. People who were in a car wreck and smashed through a windshield refuse care. People with a blood pressure of 70/20 refuse care. People hit by cars at freeways speeds refuse care.It's just nuts how little sense some people have. Shot with a rifle? Just put a little bacitracin on that. Ice it too. No problem.

  64. What guidelines don't account for is real life.Tom, if I ever am in a similar position, I want you or your counterpart to attend. Never mind “little white lies” or even “Big Grey Lies”….tell me whopping black lies, if that's what it takes. What those commentators who criticise your actions need to remember is that once dead, there's no changing your mind!

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