The most important chart she’ll ever write

Or he…I dunno.

What I do know is that the Trayvon Martin George Zimmerman situation has got us right back at each other’s throats just in time for the weather to turn nice (sorry Kansas, I didn’t mean it that way).  With the release of some video of the suspect in the police station soon after the incident surfacing, suddenly everyone is a medical expert.  Trouble is, there is only one document that can solve this problem of “was his nose broken and head bleeding?”

 

The PCR.

 

According to reports the suspect sustained injuries and was given “first aid” in the back of the police car by paramedics.

Now, because it’s the “media machine’ we have to assume everything specific is actually vague, right?  So it may have been a BLS unit, a police officer/EMT or a full fledged ALS response unit.

Despite your preconceptions about the case, because you DO have one regardless of the facts, imagine yourself on this response: (I designed it this way, this isn’t how it happened)

PD requesting ALS unit code 3 for GSW victim.  On scene they advise the victim is DOA but another person, in the back of the police car in handcuffs, needs medical attention.  Your partner confirms the DOA while you attend to the person in the police car.

After assessing his injuries, what does your chart include?  That he is in the police car?  handcuffed?  Is he in custody?  Under arrest?  What about your physical assessment?  Is it any less complete because he’s sitting in the back of a police car at night?  Do you move him to the ambulance?  Do you bandage wounds?  Do you clean wounds?  Do you clean clothes?

After deciding a refusal of care or no indication for transport, how is this documented?  Refusal? AMA? It depends on the injuries, sure, but if the patient is handcuffed in the back of the police car, does your system have a cut and dry policy for who can sign for them?

All these questions of what happened when and to what severity are hinging on what could possibly be a poor chart.  A chart that will not only be seen in court, but the way things are going, will be plastered all over FOX News and MSNBC for years.

Writing your chart for CYA takes on a whole new meaning these days.  Do it right. Every time.  You never know when a seemingly straight forward case hangs a hard right turn and crashes into a wall.

 

I’ll leave comments open if they focus on the importance of documentation in an EMS reference.  If I start to see a “debate” of the race-baiting, racist, self defense, stand your ground law, gun nut, 2nd amendment hater BS this has turned into I’m closing comments.  Let’s talk EMS here folks, sheesh.

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11 thoughts on “The most important chart she’ll ever write”

  1. It’s definitely an eye opener to never slack on any PCR. You may just make or break the patients life from there on out, regardless of the situation.

  2. Not only is this a good example of the importance of an accurate PCR, it’s a good argument for why there needs to be one at all.
    There was recently an incident in our area where we were not called and I think we should have been. It may be that the cops on scene decided the person was not in need of medical care, but when and under what conditions do they have the authority to make that decision? What if it turns out that it matters, a lot, whether that person had any injuries at all, even those minor enough that they would likely have signed off?
    What with all the different information being bandied about in the case you mention, I’d sure like a look at that PCR. I hope it’s a good one.

  3. Not only the assessment of Zimmerman, but the assessment of Trayvon Martin as well.

    Let’s hope they covered their bases when they declared him, and didn’t do something foolish like disturb the clothing or classify things as entrance/exit wounds.

  4. I’m a 2nd year paramedic student from England & I’m still trying to learn what to write & what not to write, I get antsy if I see any gaps on the free text. Thanks for another great post!

  5. We have no policy but, I have rules and the examples are:

    I have had multiple runs for assisting pd for a “man down”, “not acting right”, etc.  No pt contact as when FSTs are being preformed and the person is taken in custody and then refuses when the OFFICER asks if they want an ambulance.  Those are a disreguard by PD stated over the air and recorded.  If I speak with the person they become a pt and a refusal is documented including that they are in police custody.  This always includes a completly documented physical exam and hx and per our protocols a call to med control for altered mental status.

    I have had the PI/PD accident where the driver is intoxicated and detained and they decide they want an ambulance.  I have never had a problem with PD and they are treated like any other pt.  If it is a Misdameanor here they just let them go with us and file for a warrant later.  In fact in the intrests of the county’s pocketbook at works better that way because it makes the pt responsible for the bills.  I have had pt’s in custody for felonies and the officer rides in.  If it is a refusal the pt signs the refusal unless they refuse to sign.  At that point document the refusal to sign and get witness signatures.

    I have never had an officer say a pt could not go with me.  If it happenned I would probably just put the information over the radio so it was recorded and obtain a signature from the officer and witnesses.  If they wanted to put their career on the line that is their buisiness.  They have a badge and gun and will probably lose that lawsuit.

    I would be interested to hear Motorcop’s take on if and when an officer may or leagaly could deny an ambulance to a person being detained or in custody…

  6. Okay, question from one of the non-EMS readers…
    One of the injuries being listed for Zimmerman is having his head bounced off the concrete one or more times.  So you have a patient with a possible head injury who is experiencing great emotional stress and possibly shock, (unless he is a complete psycho, but that’s another argument) is he capable of signing a refusal?  Under ordinary circumstances getting his head smacked might leave him a bit dizzy but aware enough to decide on his own treatment.  Under ordinary circumstances a fight/shooting might put him under emotional stress but able to understand the medics treating him.  But what about when those two are combined?  Does that change your interaction with him as a patient?

    Also, having read a few cop’s take on self-defense shootings, it seems common that the problem the police face isn’t getting the shooter to talk to them but getting the shooter to shut up long enough to be mirandized.  Like someone that’s been through anything traumatic they tend to babble a bit.  So as a medic do you note what they are saying in your report?  “Came out of nowhere,” being mumbled will have a different spin in court than, “I shot him.” 

    Just a couple of thoughts that popped up.

    BGM

  7. As a general rule, the first thing do on these calls (barring immediate life threats) is ask PD is if the patient is in custody or not.  If the patient is not in custody, then as far as I’m concerned, PD are in the same category as other first responders and the decision on treatment/transport is entirely at the discretion of the patient.

    If the patient IS in custody, there’s one key difference.  If the patient refuses, but PD orders him to the hospital, then I’m taking the patient to the hospital.  The patient can still refuse any treatment (IV, bandage, vitals, etc…) s/he doesn’t want; but s/he doesn’t have a choice in destination when s/he is in police custody, and better they go to the hospital in an equipped ambulance than in the back of a squad car in case their condition goes bad quickly.

    I’ve never had a case where the police refused to allow me to transport, though I’ve had a couple of close calls.  If an officer did absolutely refuse to allow the patient to go to the hospital, I’ll probably do what I’ve told them ones who came close: get their name, signature, and badge number on the AMA form (witnessed), and make it clear on the radio that the refusal was by PD and not the patient.  As a side note, I’ve only had these problems with Highway Patrol, never with city police or county sheriff’s departments.

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