Police/Med Clearance

[thegenius]

I feel a bit like a chump asking this. As I should know the answer. But not 100% confident.

Last night police brought in this f^%ktard dude for clearance. They arrested him for a DUI and brought him to jail, and he somehow cut his finger on something while at jail. The intake nurse at jail said "send him to the ED for medical clearance for his finger."

He comes in yelling "i don't consent to medical care! I don't consent to being arrested. These cops arrested me unlawfully! His name is blah blah!!!! I don't consent to anybody examining me!!!" Yelling at the top of his lungs. (as a side note I was talking to another patient at the time, and he said "I don't know how you do this job at 2:00 AM")

When I see him he's being a total a-hole. However...he makes great eye contact. He is actually somewhat redirectable based on my questioning. There is no e/o head trauma. Pupils are mid. I do manage to look at his finger and it's a tiny cut that would do just fine with a bandaid. So the question is...

Can this guy, in this state (presumably intoxicated), legally refuse medical care? He doesn't want medical care. In my judgement he didn't need anything more than an MSE for his finger.

(after I looked at the finger the RN put a bandaid on him and I immediately remanded him to police, for what it's worth)

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[migm]

If he understands the r/b of his care then he can make a decision himself unless there's a court order. If he can't then you have to decide whether the risks of getting the treatment are worth it or not (are you gonna sedate this guy to fix a laceration? maybe). Whether or not its a suicidal thing can get a little tricky imo.

 

[filhodeinferno]

I feel a bit like a chump asking this. As I should know the answer. But not 100% confident.

Last night police brought in this f^%ktard dude for clearance. They arrested him for a DUI and brought him to jail, and he somehow cut his finger on something while at jail. The intake nurse at jail said "send him to the ED for medical clearance for his finger."

He comes in yelling "i don't consent to medical care! I don't consent to being arrested. These cops arrested me unlawfully! His name is blah blah!!!! I don't consent to anybody examining me!!!" Yelling at the top of his lungs. (as a side note I was talking to another patient at the time, and he said "I don't know how you do this job at 2:00 AM")

When I see him he's being a total a-hole. However...he makes great eye contact. He is actually somewhat redirectable based on my questioning. There is no e/o head trauma. Pupils are mid. I do manage to look at his finger and it's a tiny cut that would do just fine with a bandaid. So the question is...

Can this guy, in this state (presumably intoxicated), legally refuse medical care? He doesn't want medical care. In my judgement he didn't need anything more than an MSE for his finger.

(after I looked at the finger the RN put a bandaid on him and I immediately remanded him to police, for what it's worth)

I ran into this a few months ago and also didn't know what to do. Guy threw himself off jail bed, comes in with big scalp lac and hematoma. Needed a CT and lac repair, but wasn't concussed or altered. He refused care, but his lac was so big it was obvious it wasn't going to do well being left open. Cops refused to take him back in that condition, wanted me to put him out and fix it.

Obviously, I didn't do that, and luckily I was able to convince him to consent after some persuasion and warnings of what could happen if he left it. I'm not sure what I would have done if he was persistent. I guess I would have discharged him AMA from my care and told the cops that they have the option of taking him in like that or letting him walk...

 

[MechEDoc]

I think these are best answered on a case-by-case basis with at times involving legal consultations.

Overall, put the best interest of the patient first and act in a reasonable manner and you will likely have a very defensible case even if there is a complaint.

Capacity is a continuum. The amount of capacity to understand the risks and benefits of closure of a partial thickness uncomplicated laceration that will heal well by secondary intention is minimal. The amount of capacity to understand a nuanced and highly concave work up for possible syncope/vertebrobasilar artery TIA in a patient with multiple risk factors, and an unclear history, capacity requirements are going to be much higher. Many geriatric patients are consistently flirting on the edge of capacity with respect to complicated problems.

With a Band-Aid example I would have just discharged the patient. With the head laceration example, this becomes more complicated. I had a similar patient, however he was already under a custodial sentence (e.g. his probation was revoked or something similar). The patient clearly needed medical care, he was refusing care, and it is unclear if he had capacity (possible closed head injury) vs was being a jerk or something else. Law enforcement was unable to clarify whether I could legally treat him against his will, including using involuntary sedation. Ultimately, the district attorney was contacted and clarified that we were legally allowed to provide medical care as appropriate against the patient's will. While this is not a final legal determination, I find it hard to imagine that I could get in serious trouble providing good faith care in the patient's best interests after seeking clarification from a district attorney regarding a patient in the custody of the state.

With respect to the example given above with the head laceration and the patient with clear capacity. I suspect many physicians would sedate the patient, repair the laceration, and discharge the patient to jail. I do not know if this is legally correct, however I suspect nearly all of these cases nothing will come of it. The patient is disenfranchised by the system, will not know how to effectively use the system to cause problems for the physician, law enforcement will not complain, and most nursing staff simply want to get on with their shift and go home at the end of the day without undue heartache. If the physician is liked, the actions seem reasonable, and there are no further complaints, nothing will likely come of this. Many of my colleagues would not hesitate to knock someone out like this and get on with the job.

Every scenario will be different.

 

[GeneralVeers]

Unless these lacerations are life-threatening, I don't repair them if the patient won't give consent. Simple dressing and/or steri strips are sufficient. Who cares if the guy gets a scar? You have evaluated him for an emergency medical condition, treated any other conditions to the extent the patient will allow and have medically cleared him.

Head CT is pretty easy to determine. Criteria for possible SDH? Sedate and scan. No criteria? Wound care and discharge.

 

[Vandalia]

Maybe it was just a local trend, but for a few years there was a rumor going around the county jail that if you were sent to the ED for an injury/illness and refused consent for treatment the jail would have to release you. I found the best approach for things like the laceration was to say "OK, I will be back in a few minutes to see if you have changed your mind."(*) During which the officers would explain his options were to stay here for an hour and get it treated, or go back to jail immediately as is. The vast majority of the time they would then consent to treatment.

I assume that after the inmates who kept professing this rumor kept coming back to jail, it sort of died out.

EDIT: To be clear the scalp lac w/ no neurological signs, not the "pinky boo-boo"

 

[Birdstrike]

I feel a bit like a chump asking this. As I should know the answer. But not 100% confident.

Last night police brought in this f^%ktard dude for clearance. They arrested him for a DUI and brought him to jail, and he somehow cut his finger on something while at jail. The intake nurse at jail said "send him to the ED for medical clearance for his finger."

He comes in yelling "i don't consent to medical care! I don't consent to being arrested. These cops arrested me unlawfully! His name is blah blah!!!! I don't consent to anybody examining me!!!" Yelling at the top of his lungs. (as a side note I was talking to another patient at the time, and he said "I don't know how you do this job at 2:00 AM")

When I see him he's being a total a-hole. However...he makes great eye contact. He is actually somewhat redirectable based on my questioning. There is no e/o head trauma. Pupils are mid. I do manage to look at his finger and it's a tiny cut that would do just fine with a bandaid. So the question is...

Can this guy, in this state (presumably intoxicated), legally refuse medical care? He doesn't want medical care. In my judgement he didn't need anything more than an MSE for his finger.

(after I looked at the finger the RN put a bandaid on him and I immediately remanded him to police, for what it's worth)

Have the guy wash his finger in the sink and get him the hell out of there. So, he refuses a tetanus shot, bfd.
Next patient.

 

[thegenius]

I ran into this a few months ago and also didn't know what to do. Guy threw himself off jail bed, comes in with big scalp lac and hematoma. Needed a CT and lac repair, but wasn't concussed or altered. He refused care, but his lac was so big it was obvious it wasn't going to do well being left open. Cops refused to take him back in that condition, wanted me to put him out and fix it.

Obviously, I didn't do that, and luckily I was able to convince him to consent after some persuasion and warnings of what could happen if he left it. I'm not sure what I would have done if he was persistent. I guess I would have discharged him AMA from my care and told the cops that they have the option of taking him in like that or letting him walk...

Such a hard situation. I don't know if there is a simple answer to any of this stuff. Yours was potentially much more devastating and difficult than mine.

 

[deleted109597]

Lacerations are very rarely emergencies. We repair them for cosmesis.
Tendon lacs, cuts that go into body cavities, those can be emergencies.

The jail can refuse to take them back, but they can't make them stay at your ER.