Section 12

[CapeCodMermaid, RN]

I don't want to turn this into a rant about Paramedics and EMTs but I am steamed. We called the local ambulance company to transport a resident to a psych facility. We told them it was a Section !2 and the name of the facility they needed to take the resident to.

They arrived on the unit, had the resident get on the stretcher. Then asked if we had internet access because they needed directions to the psych facility. The resident heard this and flew off the stretcher...took her shoe and broke a window. It took us more than an hour to calm her down. I ended up calling the ambulance company. Yah so okay, one of them was brand new. Do you send a brand new driver on a Section 12? Then they told us we would have to inject her with a sedative to quiet her down. Now wait a minute, buster. If you had prepared before you came in my building, she would have been gone already and we do not and can not hold people down and inject them with psychotropics against their will.

Finally my nurses were able to convince this woman to get on the stretcher. This happened last week and because the woman was 'so upset' they took her to the local ER. It took me a week to find another bed and I wasn't going to go through this again.

I don't think I'm asking too much for the drivers to KNOW where they are supposed to be going BEFORE they arrive on the unit. We told the dispatcher and assumed the dispatcher would have told them. Have they never heard of a GPS???

[RENAISSANCE RN]

I know what you are talking about, it happens all of the time. On a transport they send emts not paramedics. I would complain to the ambulance company you use. I am sure they want your business.

Is there a reason why she wasnt medicated prior to transport ie something po??

[Medic/Nurse, BSN, RN]

Hey there CCMermaid -

I understand your frustration.

I, too, do not want to engage a rant on EMS.

I think that it is reasonable to expect that an ambulance company be prepared for transport. Knowing the directions to a facility is essential to getting there. I also think that the ambulance company should also be told all essential patient info for safe transfer.

I think that PSYCH is tough on everyone. It sure does eat up staff resources when it occurs as an emergent problem.

Did the ambulance company err on the dispatch? Perhaps, regardless - if I do not know how to get somewhere I am going to have to ask. They should have quietly started at the desk (out of the earshot of the patient)* -- received report, ensured that the paperwork was "in order" and then printed out Mapquest directions if necessary. Maybe this crew had not been back to the station and came from another transport. Not ideal, but maybe that was the best option they had.

*Rant here! I am never comfortable getting report on psych (actually all) patient transfers at the patients bedside. So to all the great nurses out there - remember that the transport team knows nothing about the patient they are going to be caring for - sure, I'll get to my assessment, but I ALWAYS appreciate nurse to nurse report at the desk.

I would count myself lucky that ambulances do "sectioned" transports in your state. Some states that I have been in requires that LEOs do the transport - because the patient is not voluntary -- they are being treated within the provisions of a law that allows they transport/treatment against their will.

FIRST, the "brand new driver" on a Section 12 - Well, how dare that ambulance company do that!? I'll caution that "ambulance driver" references are generally demeaning and offensive. Next, as much as you wanted the patient out of your facility the standards of care for transport still exist. Actually, psych transfers have some aspects of liability (patient confinement, mental status) that make them exceptional. IF this patient was "sectioned" as you reference were they able to refuse treatment/transport? From the info in your post - was the patient AWARE that they were going to a PSYH facility? I'm guessing that the need for directions is not the INFO that caused this patient to act out. I'm guessing that when the patient heard they were going to a psych facility --- that is what pushed the button!

SECOND, I'm confused by the problem with sedation for trip. This patient had already been violent. I'm not going out into a confined space in an uncontrolled environment with this patient UNLESS I have a provision to do so safely (for the patient, my crew and the public). Maybe this "sedation" issue was necessary for safety. You note that holding down and injecting with meds against this patients will is a CANNOT/WILLNOT situation - back to the voluntary vs. involuntary issue. If this is a Section 12 transport - can the patient really refuse sedation or just transport or just walk out? I think the ambulance crew was reasonable with the sedation request - imagine the problems leaving a facility with a knowingly agitated, violent patient.

Sounds like a meeting with your facility's risk manager & clinical educator and the ambulance company's risk manager and clinical educator should be a priority - then an inservice for all on treatment and transport of Section 12 patients.

I find that most problems stem from violations from expected outcomes. When everyone know what to expect from the other - it makes for better patient care. And lets harmony flourish!

Good Luck.

Practice SAFE!

[Kyrshamarks, BSN, RN]

I read the Massachuestts Section 12 law, and it says that you may restrain the Section 12 patient and that includes chemical restraints. The patient is being involuntarily committed and thus you have a duty to properly restrain this patient becasue the belief is there that the patient is a dangerto onself or others. As a former "ambulance driver" (I hate that term) I would never take an unrestrined commited patient to a psych hosptial without them being 1) physically restrained or 2)chemically restrained 3) or both types of restraints. Also are you so sure that the ambulance crew was given the right info on the original call such as the correct hospital? Many times we showed up for a transport and found out we were going to a completely different hospital than we were told and sometimes this other hospital was in a different town and we would not know how to get to it seeing as it is not one of our normal hospitals. This was in the day before computers were prevelant and there sure was not a map quest....

[CapeCodMermaid, RN]

We do not use chemical restraints without consent even in a section 12. My point was that had the EMT done what any reasonable person would have done, ie. get the directions BEFORE the patient willingly climbed on the stretcher, the whole thing could have been avoided.

[Rexie68]

just curious...do you never "hold someone down and inject them" with a sedative/psychotropic med? certainly not a common occurance, but i've done it with someone who was deemed a danger to himself or others. that's why we have one or two residents with a prn im zyprexa/haldol/ativan order. most of the time we can talk them down, or give them space, etc...but when they're insistent upon attacking someone because they're delusional and think we're all nazi's, well, we just have to do it. sometimes i wonder if it's this way because we're trying to get rid of the psych meds so much that we end up getting rid of some that are truly needed.

my favorite emt/paramedic...the one that seems angry that i called him for my lol with a suspected fx hip. i know it's a boring call, but she needs transport...and i can't just load her into my car for the trip to the er....

[CapeCodMermaid, RN]

I've worked in 10 facilities and at no time did we ever hold someone down. Never had an order for IM Haldol. Only time we ever gave IV Ativan was for a seizure.

Did you work in the same place I did? We had a woman who thought we were all Nazis because she worked for the French Resistance during WWII. She pitched a nutty one day and we couldn't get her to calm down. Finally it dawned on me to try speaking to her in French. It was like a light switch. She ran to me and we 'escaped' from the Nazis by going in the secret tunnel (also known as the shower room---it had a door on either side of the hall). It was the only time she ever went that far. She forgot most of it the next day.

Thank you Mrs C and Mr. H from high school French class.

[noc4senuf]

When i worked in WI, I did not allow IM psychotropics in the facility, or any Haldol in any form. Also, it is called a Chapter 51 when someone is sent out for psych issues. They are transports by the police dept.

In MN, we do have those available but, we can not give them if a resident refuses. Our solution is to have the med compounded. We have a pharmacy that specializes in compounding meds. It arrives in a tiny 0.5 cc syringe and the ointment looking med is applied on the wrist and absorbed. We have done this with psychotropics, narcotics, antidepressants. It works great for residents that are unable to swallow meds too.

[Rexie68]

when i worked in wi, i did not allow im psychotropics in the facility, or any haldol in any form. also, it is called a chapter 51 when someone is sent out for psych issues. they are transports by the police dept. quote]

here in pa they're called 302's.

anyhow, why no haldol in any form? we have a few residents who've responded well to haldol when nothing else seemed to work.

no im psychotropics at all? impressive. unfortunately we end up using one about once every 2 months, in my guesstimation. zydis is a wonderful thing, but still doesn't work if i can't convince the lol to open her mouth. the compound idea sounds interesting!

[noc4senuf]

I just never like Haldol. It is an old drug and seems to have been invented to make zombies out of my residents. There are much better suited drugs on the market. As for the IM's, most of them have a long half-life and to be used as a PRN isn't the best. Besides, the state would have a real fun time if IM psychotropics were used.