“Ya’ll need to get out of my house.  I don’t need to go to the hospital.”  He was slurring his words and was obviously drunk.  “I will go see the V.A. tomorrow if I need to.”

His right leg was snapped in half near the ankle.  Both the tibia and the fibula were broken and his boot was actually lying sideways on the carpet even though he was sitting on the couch with his leg perpendicular to the floor.

“Sir, come on.  Your leg is obviously broken.  I am not joking when I am telling you that if you don’t have that treated today, they may have to cut that off and you will be an amputee for the rest of your life.”  This conversation had gone on for about 15 minutes, and I was pulling no punches.

“I told you to leave me alone, damnit.  I’ll be fine. Get on out of here.”

According to neighbors he had been drinking all day long and for some inexplicable reason decided to use a chainsaw to cut down a tree in his yard.  He got towards the end of the cut and jumped to get out of the way.  As he did, he slipped in the mud and his leg got caught in a fence that was directly behind him.  As the tree fell, the trunk swung up and then back down again, snapping his leg in half.  One of his neighbors saw him dragging himself back to his house on his belly and called 911.  And there he sat, drinking bourbon and smoking cigarettes, and telling us he was fine.

A police officer had arrived on scene before us and was trying to help.  I asked if he could arrest him for public intoxication and then make him go to the hospital.  He said he couldn’t do that if the patient was in his own home.  Then I asked about a mental inquest warrant.  People who are obviously a danger to themselves or others can sometimes be declared by a judge to be mentally unfit and the police are allowed to transport them to a hospital for treatment.  The cop’s face brightened and he snapped his fingers in the air, “Now that’s an idea!  I’ll be outside talking on the cell phone.”

The two EMT’s who had responded with me were struggling to get him to allow a set of vital signs.  He was still refusing.  More neighbors had started to congregate on the porch and some were attempting to talk some sense into him.  It wasn’t working.  My partners had also found deep cuts on both his hands that needed stitches.

After a few minutes the cop came back into the house with a frown on his face.  “I just talked to every attorney that works for the county and every judge I know of and none of them will touch it.  One of them actually yelled at me for bothering him with this ‘stupid shit.’ I can’t do a thing.  He has the right to be an idiot.”

After a while the patient started to talk about a friend of his who was a nurse.  We instantly got her on the phone and she drove to our location.  While we waited I continued to try and convince him.  “All she is going to do is tell you to come with us.”

“Nope.  No, I’m telling you.  She will drive me to my doctor.  She knows what to do.”

It was no use.  We waited another 15 minutes until she arrived, called him a moron, and told him to shut up and get on the stretcher.  Only after that did he consent to treatment.  Forty-five minutes had passed since we first made scene.  It took us ten more minutes to package him up and begin transport.

The accepting doctor gave our crew some static, trying to say that we could have taken him against his will because he was drunk.  I hate it when uninformed doctors just repeat something they heard around the water cooler and try to pass it off as official policy.  I have asked many lawyers about this as well as read the Kentucky laws that pertain to restraining patients.  There is no legal basis for it.  If a police officer consults multiple judges and attorneys and is told to leave it alone, how on earth can I just walk up and tie him down to my cot?  The thought is absurd.  How do I know he is drunk?  And what if he is?  Does that mean that if I have three beers and one of my neighbors calls 911 I can be forcibly removed from my home by any EMT who shows up and thinks I need treatment?  Of course not.  And by the time I got done with them they would have to rename the place “Buckman’s Ambulance Service” because I would own it.

Here is the excerpt from the KRS (Kentucky Revised Statutes) that deals with involuntary hospitilization.  Notice there is no mention of EMS here.

202A.041 Warrantless arrest and subsequent proceedings.

(1)        Any peace officer who has reasonable grounds to believe that an individual is mentally ill and presents a danger or threat of danger to self, family, or others if not restrained shall take the individual into custody and transport the individual without unnecessary delay to a hospital or psychiatric facility designated by the cabinet for the purpose of an evaluation to be conducted by a qualified mental health professional. Upon transport of the person to the hospital or psychiatric facility, the peace officer shall provide written documentation which describes the behavior of the person which caused the peace officer to take the person into custody. If, after evaluation, the qualified mental health professional finds that the person does not meet the criteria for involuntary hospitalization, the person shall be released immediately and transported back to the person’s home county by an appropriate means of transportation as provided in KRS 202A.101. If, after evaluation, the qualified mental health professional finds that the person meets the criteria for involuntary hospitalization, appropriate proceedings under this chapter shall be initiated. The person may be held pending certification by a qualified mental health professional and implementation of procedures as provided in KRS 202A.028, 202A.031, or 202A.051 for a period not to exceed eighteen (18) hours.

Even psychiatric patients who have been diagnosed with a debilitating condition such as schizophrenia have extensive protection under the law and cannot be treated without consent.  Edwin Leap has a sad but moving post about this on his blog.  In this post he talked of having to release a known schizophrenic and let him chose to be homeless even with his mother present and begging for help.

A lawyer once explained it to me like this, “Can someone just come to your home and tie you down and cart you off?  No.  Do you want to live in a world where that can happen?  No.  That patient isn’t any less of a human being than you are.  As long as he is conscious and is alert and oriented, that patient has the same rights as you or any other citizen in these United States.”

Civil rights must be protected at all costs.  This is obvious.  But there are so many people in our country who may be alert and oriented by the legal definition, but are in obvious need of help and are in jeopardy.  Any practitioner who has taken an oath to do no harm may not be breaking that oath by letting someone go, but it sure is difficult to walk away from a patient who may die or suffer a permanent disability if they do not seek treatment.  Families feel free to annoy services with lawsuits claiming damage after abandonment even though it is obvious that they never consented to treatment.

How did we get here?   Unfortunately, we got here due to decades of patient abuse which forced us to enact such strict safeguards for patient’s rights that many people that truly need help fall through the cracks.  For years mentally ill patients who had families that could afford treatment were sent to sanitariums.  And there they stayed for the rest of there lives.  The ones that couldn’t afford treatment wandered homeless and many populated our prisons.  Sometime after World War II the use of barbiturates and other drugs finally gave some relief to psychiatric patients and modern treatment began.  In the early 60’s JFK helped pass legislation that made it possible for more psychiatric illnesses to be treated as outpatient illnesses.  This was also the dawn of much civil rights legislation which progressed and continued through the 70’s.

Today we have a very different landscape.  Patient’s used to disappear into sanitariums for the rest of their lives.  Now you are lucky if you can put a patient on 72 hour hold.  This was a move in the right direction, but I don’t think I have ever talked to an emergency healthcare worker who was not frustrated with the current laws in some way.

In the early 90’s before I was in healthcare, my father came to me with a strange proposition.  A friend of his had a son with a horrible drug problem.  He had been part of several in-patient programs until his insurance had maxed out and he had never been cured.  He had reached the age of 18 and was now refusing all care.  His father would occasionally lose track of him and would go looking in the usual places.  He would find him living homeless and would bring his son home and try to sober him up.  Once his son could function again he was out the door to delve into more destructive behavior.  His son knew what to say to avoid in-hospital treatment.  He knew that if he denied suicidal ideation and stayed oriented to name, time and place that no one could touch him.  His father had found a treatment facility out of the country.  I do not remember exactly where it was, but it was somewhere like the Bahamas.  His plan was to basically kidnap his son, charter a plane, fly him to this in-patient facility outside the restrictive laws of the United States, and finally get him some help.  The trick was that he was not going to consent to this, and I was being asked if I could perform the muscle work to make him get on the plane and keep him there.  We had quite a few conversations about the plan, but fortunately it never occurred.  He did consent to treatment after he hit rock bottom.

Unfortunately, most laws about consent are written with the psychiatric patient in mind.  This is true in Kentucky, where the law even states that patients being transported to a hospital for a 72 hour hold must be transported by a police officer.  It is a common misconception that EMTs can do this, but the law clearly states that a “Peace Officer” must perform the transport and there is actually no mention of EMS.

How do we solve this conundrum?  Our law makers are going to have to revisit this and make a decision.  If we are to err on the side of civil rights, then let’s come up with a standard assessment for competent decision making abilities and write a law that states that patients who pass this assessment may refuse and may not sue after the fact.  Police officers often wear microphones that record conversations, why can’t EMS record patient refusals?  It may sound cold, but I would be fine with having our leg fracture patient sign AMA.  As the office said, “He has the right to be an idiot.”  If a patient wishes to be an idiot I can clear up my crews for other runs and let natural selection take its course.

If we are allowed to take people against their will then we need strict guidelines on restraint, report writing, and we need police involvement.  We also need more testing equipment in the field, because “I think he was drunk” is not going to cut it.   Yes, the days of the sanitarium are gone.  They have been gone for decades.  Twentieth century psych care is just that, twentieth century care.  If you haven’t noticed, this is the 21st century.  Its time to make plans for a Patient Consent 2.0 in which we are able to either make people get the care they need or be immune from the resulting lawsuits.

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