My Call! I'm In Charge!

One night, long long ago, I was attending when my bus was assigned to an auto-ped. We were a little bit away from it, so it took us five or seven minutes to get there. On the way, about halfway through our response, dispatch advised that an ambulance from a private EMS service was on the scene. Let’s call the private company “XYZ” for the sake of storytelling.

Good, I thought. I won’t have to work. Let them handle it and I can go back to eating.

My partner and I got on scene and strolled over to see how things were going for the private crew. Three important things need to be mentioned here. First, I am fully down with someone else doing a good job on a call. Knock your bad selves out. I don’t need to steal good calls. Second, I like to help if I can help. Sometimes you need an additional pair of hands.  Finally, it is my city. My agency is responsible for EMS in the jurisdiction. I have a responsibility to make sure care is being performed reasonably well, at a standard consistent with the expectations we have in the city. So I walked up and asked how things were going.

“This is my call! I’m in charge!” The XYZ medic wanted to make sure I knew who was in the leadership position.

“Great. Need a hand?” I offered.

“I’m running this call!” He shouted. He would have done better to give me a task.

One great piece of advice I received in paramedic school was that if you feel the need to announce that you’re in charge, you’re not. Someone in charge should be directing the scene, making decisions, delegating tasks, and otherwise generally being in charge without feeling an overwhelming need to loudly declare the fact.

I looked around and absorbed the scene. The patient was an adult male with a visible open tib-fib fracture on the right leg. He looked to be awake, but upset and hurting. Dude looked a little pale to me, but that may have been due to a pain response resulting from his leg. He was fully clothed, except for his right pant leg being cut from the cuff to knee level.  He wore a cervical collar. There was an XYZ EMT at the patient’s feet, putting a SAM splint on the busted leg. A backboard was on the ground next to the patient. (What with the backboard and C-collar, you can tell this was a long time ago…)

Considering the patient’s pallor and the fact he was hit by a car, I wondered about his vital signs. I was hoping he wasn’t hypotensive. I asked about the blood pressure and was informed they hadn’t checked it yet. Okay, maybe they were prioritizing packaging and scene departure. I asked about the patient’s heart rate. They told me they hadn’t checked that yet, either. I asked about verbalized complaints. Hadn’t asked. I inquired about the rest of the secondary exam. Nope. They hadn’t gotten around to it yet.

I silently wondered what they had accomplished and lifted the patient’s shirt. There I found a tire track across dude’s belly.

The XYZ crew was splinting the leg and hadn’t found the tire track yet.

At that point, I announced that I was taking the call over and getting the hell out of there. I asked my partner to pull our wheels and “set me up.” He would know that I was looking for two blood pumps to be hung and for a couple of 14s to be tossed onto the bench seat. I directed the firefighters to logroll the patient onto the backboard, and then onto the bed. I told the police we would be leaving the scene in two minutes and they should go to the trauma center for a victim statement. Everyone looked relieved that decisions were being made.

Everyone but the XYZ medic, that is. He plum lost his mind. He literally jumped up and down. Spit flew when he screamed about it being his call. His hands were balled into fists and he was quivering with rage. I asked him to step back. He loudly declined by issuing a string of profanities, so I asked a nearby police officer to help him step back. The police officer smiled and took the apoplectic medic by the arm and led him over to the sidewalk, away from the scene, yelling the whole time about the arrogance of the city medics. The XYZ EMT helped roll the patient onto the backboard and then stepped back, too.

Transporting to the hospital, the call was fairly straightforward. The patient was maintaining his own airway, tachy but normotensive, and complaining of pain in his abdomen, pelvis, and lower leg. I got him naked, finished the physical exam, popped a couple of IVs into him, and set up the hospital.* We arrived and I gave the big room report.

The ED attending doctor was one that I throughly respected (and kinda feared, if I am being honest). He was a phenomenal doctor who was very perceptive and had high expectations for the performance of everyone around him. He was definitely not afraid to call out a bad job, even a little bit. It made him intimidating to me, especially as a new medic. “Who put that splint on?” he asked me irritably, glaring at me and pointing to the SAM splint on the patient’s ankle.

“XYZ” I gave him the private ambulance company’s name. I didn't put the splint on, but I still felt guilty. That was the affect this attending had on me.

“XYZ?” he confirmed with one eyebrow raised.

“XYZ,” I repeated with my hands palm-forward in front of my chest. “I wouldn’t have wasted time with it.” At best, I would have splinted the leg using the other leg, the backboard, towels, and some tape. But only after everything else was done. It is certainly possible to die from abdominal tire tracks, but not as often from broken lower legs.

“Look at this,” he directed with a disgusted tone in his voice. He showed me the patient’s lower leg. The splint ended about four inches below the fracture. It wasn’t even high enough to immobilize the break, let alone the joints above and below.

I have never been so glad to not be the one to put on a splint.

*This was back when we were stingier with pain meds. I would give him some opiate analgesia nowadays.

I Hate Transporting (Some) Narcan Patients

I am not your boss, supervisor, manager, or medical director. I have nothing to do with your protocols, policies, QA reviews, or your ability to continue to receive a regular paycheck. I also do not fill an official role in Denver Health, so the thoughts below are my own opinions. You know about opinions, right? Adopt the concepts below at your own risk.

You are assigned to the report of an unconscious party in a nearby apartment and arrive to find a patient as advertised. The patient is a mid-twenties male with pale skin and miosis. He has a heart rate of 100 beats per minute and his respiratory rate is so slow that you get bored counting it and estimate it to be about four per minute. A heroin rig is on the end table next to him. You administer 0.5mg intranasal Narcan and add a few breaths via a bag-valve mask while you are waiting for him to wake up. After a few minutes, the patient wakes and begins to breathe normally. There is no indication of co-ingestion, alcohol use, or other medical concerns. The patient’s heart rate slows to 70 beats per minute and his oxygen saturation is 99% on room air.

Wikimedia Commons

The patient seems to be a pretty nice dude. He is rather ashamed you had to wake him up. He explains that he had been clean for about nine months, but had just experienced personal stress and fell off the wagon. “I guess I don’t have the tolerance I used to. I guess I took too much,” he tells you.

He also tells you that he doesn’t want to go to the hospital.

So here is the thing. He is completely awake now. He is answering all questions appropriately. He can tell you how many quarters are in a buck-fifty and who is president. Hell, he can even tell you who governor and mayor are. You explain to him that the smack he overdosed on may have a longer action than the Narcan you reversed it with. His overdose could return. He absorbs that information and still doesn’t want to go to the hospital.

Is he allowed to refuse transport to the hospital?

Some paramedics take all patients who received naloxone to the hospital. Some EMS protocols even require it.

Should he be allowed to refuse transport? I’m asking about what should be done, not what is mandated, or what your common habit is. What should the answer be? To me, the answer depends on patient safety and patient autonomy. Is it safe for him to refuse transport? Does he have the required decision making capacity to refuse transport?

What does published research say about the safety of non-transport after prehospital naloxone administration?

• Sporer’s group published an article in 1996 that looked at the rate of patient admission after Narcan administration (1). They report admission is rare – only 2.7% of patients transported after naloxone were admitted to the hospital. The most common reason for admission was noncardiogenic pulmonary edema, which they described as “clinically obvious.” Other causes included pneumonia, infections, and persistent respiratory and mental status depression.
• Vilke, et al., compared records from the San Diego medical examiner’s office with positive opioid test results to prehospital records (2). None of the 117 opioid-involving deaths in the ME’s records and the 317 prehospital refusal after naloxone matched within a 12-hour window. Another San Diego study (3) four years later looked at almost one thousand patients who received prehospital naloxone and refused transport. None appeared in ME records within 12 hours.
• A study from Helsinki, Finland, headed by Boyd (4) attempted to describe the incidence of recurrent toxicity and the time interval in which it occurs. One hundred forty-five uncomplicated heroin overdose patients were included. Eighty-four refused transport. Seventy-one had no life-threatening events in a 12-hour follow-up period; the others were lost to follow up. Of the sixty-one who were transported, 12 (19.6%) needed more naloxone, but all occurred within an hour. The authors specifically state: “Allowing presumed heroin overdose patients to sign out after prehospital care with naloxone is safe.”
• Wampler, et al., published a study (5) from San Antonio that was similar in design to the Vilke studies discussed above. They compared refusals after Narcan to the county medical examiner’s database within 48 hours of the refusal. Of 552 patients, none presented to the medical examiner within 2 days. A 30-day comparison of records found 9 patients who received Narcan and died, but the shortest interval was 4 days post event.
• A huge study from Rudolph’s group (6) included 4,762 cases of acute opioid overdose over a ten-year period. Only 14 patients who were released on-scene after having been treated with naloxone died within 48 hours. Only three presented with possible rebound opioid toxicity as the reported cause of death (0.13% of the patients released on scene).
• Finally, a recent study published by Levine, Sanko, and Eckstein (7) presented a multi-year retrospective review of LAFD’s records. Two hundred five refusal-post-Narcan patients were identified. One subject died within 24 hours of refusing care due to “coronary artery disease and heroin use.” Two others died within 30 days. A fourth subject died 16 months after refusing transport. “The practice of receiving prehospital naloxone by paramedics and subsequently refusing care is associated with an extremely low short- and intermediate-term mortality.”

As a final example of the safety of non-transport after naloxone administration, I give you the fact that people can buy Narcan in a grocery store pharmacy, administer it to their friends or family, and not go to the hospital. They can do all of that without involving the EMS system at all. In the imaginary case that began this post, if the patient’s girlfriend had given Narcan he could have avoided a hospital bill pretty easily.

I think there is some evidence to indicate that non-transport after opioid overdose reversal is a generally safe practice. The published research has holes, as does research on most topics, but seems to lean toward a feeling of safety. So we can consider the second point: Does the patient have decision-making capacity?

I have published my thoughts on decision-making capacity previously. In short, I don’t necessarily care if the patient is sober (although you could make the argument that I have used pharmacology to make him so) or competent. I care that the patient, at that moment,

• can make and communicate a medical choice [check],
• can appreciate the concepts of diagnosis, prognosis, suggested care, alternatives, and risks/benefits [check],
• can make decisions without delusions or coercion [check], and
• can use logical reasoning [check].

Seems to me that the patient described here has decision-making capacity.

So why must he go to the hospital? Well, I don’t think he does.

This is an example with a simple, uncomplicated heroin overdose that doesn’t present additional complications. There are no other ingestions. He isn’t rolling on an eight ball, or alcohol, or anything else. His overdose wasn’t related to a suicide attempt. He actually has the obvious ability to make decisions, and there isn’t residual confusion or mental slowness. All of those points wouldn’t exist in every case of Narcan administration. It is the subtleties of each case that make disposition decisions a giant grey area.

I am not saying the patient’s decision doesn’t constitute an Against Medical Advice refusal. My medical advice is that he be transported. People refuse against my advice all the time. We are taught that people are allowed to make decisions that we disagree with. Sometimes we disagree strongly. But the principle of informed patient autonomy is a bedrock, foundational principle of medical care.

This doesn't override your rights to self-determination. Source

But I disagree with the black and white outlook that requires transporting a patient who possesses intact decision-making capacity. People with decision-making capacity are allowed to decline transport in my world. In an ideal world, I would even add another milligram or two of Narcan IM to help make sure the overdose is less likely to return. But transport? This guy? Nah…

1. Sporer KA, Firestone J, Isaacs SM. Out-of-hospital treatment of opioid overdoses in an urban setting. Acad Emerg Med 1996;3(7):660-667.

2. Vilke GM, Buchanan J, Dunford JV, Chan TC. Are heroin overdose deaths related to patient release after prehospital treatment with naloxone? Prehosp Emerg Care 1999;3(3):__.

3. Vilke GM, Sloane C, Smith AM, Chan TC. Assessment for deaths in out-of-hospital heroin overdose patients treated with naloxone who refuse transport. Acad Emerg Med 2003;10(8):893-896.

4. Boyd JJ, Kuisma MJ, Alaspää AO, Vuori E, Repo JV, Randell TT. Recurrent opioid toxicity after prehospital care of presumed heroin overdose patients. Acta Anaesthesiologica Scandinavica 2006;50(10):1266-1270.

5. Wampler DA, Molina DK, McManus J, Laws P, Manifold CA. No deaths associated with patient refusal of transport after naloxone-reversed opioid overdose. Prehosp Emerg Care 2011;15(3):320-324.

6. Rudolph SS, Jehu G, Louman Nielsen S, Nielsen K, Siersma V, Rasmussen LS. Prehospital treatment of opioid overdose in Copenhagen – Is it safe to discharge on scene? Resuscitation 2011;82(11):1414-1418.

7. Levine M, Sanko S, Eckstein M. Assessing the risk of prehospital administration of naloxone with subsequent refusal of care. Prehosp Emerg Care 2016;20(5):__.