Professional Development--Part 11: Reflecting on Actions and Decisions

   Many years ago, I responded with my partner to a home in southwest Philadelphia. We were called to a reported fall. When we arrived we found a birthday party winding down. There were balloons, the remains of a cake and ice cream in the kitchen, little kids running around in sugar freak-outs, and a homemade banner hanging in the dining room that said Happy Birthday, Pop Pop. One of the family members took us to some stairs that led to a finished basement set up as a family room. At the bottom of the stairs we could see an old man lying on his back, his feet still on the steps, another family member holding him. As we walked down to him, it was clear he had been incontinent of urine. We determined Pop Pop had been celebrating with a bit of wine and ouzo. When we asked him what happened, he said he'd tripped on the stairs and fallen. His speech was slurred, but he was otherwise alert and oriented. We continued our assessment and found no significant injuries other than a bruise on Pop Pop's forehead. He had no complaints and denied loss of consciousness. His vital signs were mostly normal, but his blood pressure was a bit high. We wanted to board and collar Pop Pop, do a cardiac workup and take him to the emergency room for evaluation.

   The family did not want us to initiate treatment and did not want us to transport. I had a long conversation with Pop Pop's daughter and son-in-law about what could have happened to Pop Pop, and what might happen if he did not get evaluated. I told them he could have had a stroke or some kind of cardiac event that triggered the fall, or that he may have suffered a serious head, neck or back injury in the fall. The family was adamant that Pop Pop was fine, that he maybe just had a bit too much to drink. I tried to convince them to allow us to treat and transport Pop Pop. I told them there was small chance something was seriously wrong, but we couldn't tell for sure without further evaluation and tests that could only be done at the hospital. I told them Pop Pop needed to see a doctor to be certain. If he had a serious problem that went undiagnosed, Pop Pop might die. They said they would take him to the emergency room themselves later if I really thought it was so important for him to be evaluated, but they absolutely refused to allow us to transport at the time.

   I called the medical command physician on duty and explained the situation. Then I asked the family if they would talk to the doctor. They did, and when I got back on the phone, the medical command doc told me to let them sign a refusal against medical advice, and make sure the police officer signed as a witness. The call, like all medical command calls, was recorded.

   I didn't feel right about the situation. We got the signatures and made one last attempt to convince the family to let us take Pop Pop to the emergency room. They said thanks, but they'd take him later. We documented the call completely, had family and the officer sign the patient care report, and then we left.

'POP POP DIED?'

   About a month later I got a call from one of the medical command physicians at our systems resource hospital. They handled the department's quality improvement activities. He asked me if I remembered the case of an elderly man who had fallen down a staircase. He wanted to know what had happened and why we didn't transport. I said I remembered the case. He started to grill me about the details. I got aggravated and asked him, "Have you read my report or listened to the medical command tapes?" He said he hadn't. I replied, "Everything you need to know is in my report and on those tapes." Then I asked why he wanted to know. He said the family had waited until the next day to take the man to the hospital--after they couldn't wake him up for breakfast--and that he'd died seven days later after being admitted. He had suffered a subdural bleed. The family was threatening to sue.