Case Presentation

1
Case Presentation 13

• Jim Pointer, MD
• Alameda County EMS
• Medical Director

2
Complaint
Dr. Rowland called 9-1-1 because his patient, Mr.
Richard Hibbs vomited blood twice while being
seen in the doctors office. The office is
across the street from Willow Bend Hospital. You
respond to the 9-1-1 call.
3
History

• Mr. Hibbs is a 52 y.o. male with a history of
  belly pain and dark BMs for the past three
  days.
• He also had a grossly bloody bowel movement in
  Dr. Rowlands office.

4
Past Medical History

• Hypertension
• Cellulitis right arm
• Lupus
• No prior bleeding history
• Social lives alone
• Medications Prednisone, Terazosin, Cefalexin.

5
Field Assessment

• Primary survey
• Airway open blood in and around mouth
• Vital signs B/P 82/54, HR 106, RR 18
• Secondary survey (pertinent findings)
• Neuro able to follow commands, alert and
  oriented.
• HEENT Patient vomited 350 ccs bright red blood

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Field Assessment (cont.)

• Secondary survey (cont.)
• Lungs clear
• Abdomen Tender throughout, distended
• Extremities erythematous, pustular rash right
  humeral area

7
The Saga Begins
Mr. Hibbs refuses to go to the hospital in spite
of convincing by Dr. Rowland and field personnel.
Patient states he wants to go home to feed the
cats, then hell go to the hospital. River
City PD is called and officers offer to feed Mr.
Hibbs cat. Patient continues to be oriented but
now feels dizzy.
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Recheck Vital Signs

• B/P 62/42
• HR 116
• RR 22
• Patient vomits another 500 ccs
  of bright red blood.

9
Field Interventions

• Oxygen 100 by NRM
• IV Normal Saline wide open
• Pulse Ox 94
• EKG -

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The Saga Continues
The patient continues to refuse
transport. River City PD returns to place the
patient on a 5150 hold. Field personnel obtain
consultation with the base hospital physician,
Dr. Bernard, who tries for 15 minutes to convince
Mr. Hibbs to consent to transport. Finally,
Dr. Bernard instructs the paramedics to transport
to Willow Bend Hospital under implied consent.
The patient continues to refuse however, he
passes another bloody stool in the bathroom of
Dr. Rowlands office.
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and continues

• Repeat vital signs B/P 58/palp, HR 120 (radial
  pulse not obtainable) RR 24
• Continuing Course Mr. Hibbs continues to refuse
  transport. With the help of Dr. Rowland, the
  paramedics forcibly place Mr. Hibbs on a Gurney
  and transport him to Willow Bend Hospital. En
  route, the patients B/P becomes unobtainable.

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Hospital Findings

• A middle-aged male in uncompensated hemorrhagic
  shock, in extremis. Patient is Semi-comatose
• Vital signs B/P not obtainable, HR
  132 Sinus tachy, RR - 28

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Hospital Course

• Resuscitation is attempted with 14 units of
  packed red blood cells, 10 units of platelets and
  10 liters of NS.
• An emergency endoscopy is performed, and with
  difficulty, the diagnosis of esophageal varices
  is confirmed.

14
Ethical Delimmas

• Refusal of Care
• Consent
• Informed
• Implied
• Competency
• Documentation

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Refusal of Care Policy 8040

• In order to refuse care a patient must be
  legally and mentally capable of doing so by
  meeting all of the following criteria
• Is an adult (18 or over), or if under 18 legally
  emancipated.
• 2. Understands the nature of the medical
  condition,
• and the risks and consequences of refusing
  care.
• 3. Exhibits no evidence of
• ? Altered level of consciousness
• ? Alcohol or drug ingestion that impairs
  judgment
• Is oriented to Person, Place, Time, and Situation.

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Informed Consent

• Definition Process by which patient is fully
  informed of and participates in medical
  decisions.
• Elements of Informed Consent
• The nature of the decision
• Reasonable alternatives to the proposed
  intervention
• The relevant risks, benefits, and uncertainties
  related to each alternative
• Assessment of patient understanding
• The acceptance of the intervention by the patient

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Informed Consent (cont.)

• Failure to obtain consent
• Battery the intentional touching of a person in
  a harmful or offensive manner without consent

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Capacity

• Probate Code 4609
• A persons ability to understand
  the nature and consequences of
  a decision and to make and communicate a
  decision, and includes in the case of proposed
  health care, the ability to understand the
  significant benefits, risks and alternatives.

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Capacity To GiveInformed Consent

• A person has the capacity to give informed
  consent to a proposed medical treatment if the
  person is able to do all of the following
• Respond knowingly and intelligently to queries
  about that medical treatment
• Participate in that treatment decision by means
  of a rational thought process

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Capacity To GiveInformed Consent (Cont.)

• Understand all of the following items of minimum
  basic medical treatment information with respect
  to that treatment
• The nature and seriousness of the illness,
  disorder, or defect
• The nature of the medical treatment that is being
  recommended
• The probable degree and duration of any benefits
  and risks of any medical interventionand the
  consequences of lack of treatment
• The nature, risks, and benefits of any reasonable
  alternatives

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Capacity To GiveInformed Consent (Cont.)

• A person who has the capacity to give informed
  consentalso has the capacity to refuse consent
  to treatment.

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Implied (Emergency) Consent

• Definition Process under which treatment
  proceeds without the patients informed consent.
• Criteria
• Emergency condition must exist
• Alleviation of severe pain
• Resulting death or serious disability
• Patient has not refused treatment for current
  medical condition in the past
• Patient is unable to provide consent (unconscious
  or incompetent)

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Immunity From Liability

• Definition A licensee who in good faith renders
  emergency care at the scene of an emergency is
  not liable for civil damages as the result of
  acts of omission

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Immunity From Liability (cont.)

• Application
• Physician
• Scene of an emergency
• Medical disaster (even in ED)
• EMT-IIs and Paramedics
• If following, in good faith and a non-negligent
  manner, the instructions of a physician or nurse.
• A rescue team operated by federal, state, county
  government in attempts to resuscitate in good
  faith a person in immediate danger of loss of
  life or serious illness.

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Applicable Statutes/Case Law

• Informed Consent
• Cobbs v. Grant, 8, Cal. 3d 229 (1972)
• Implied (emergency) Consent and Immunity
  (physicians)
• Business and Professions Code 2395 et seq.
  (immunity in emergency situations)
• Probate Code 3210(b) - (care to incompetent
  adults without court authorization)
• Welfare and Institutions Code 369(d) and 739(d)
  - (care to minors in custody of court)

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Applicable Statutes/Case Law

• Implied (emergency) Consent and Immunity
  (rescuers)
• Health and Safety Code, Section 1317
• Health and Safety Code, Section 1799.104
• Medical Disaster
• Government Code, Title 2, Division 1, Chapter
  7, Section 8550 et seq.