On scene you find a 55-year-old male sitting on a chair in the waiting area of the station. Police are not on scene yet. There is some blood on the patient’s face and shirt but no active bleeding. His clothes are soiled with dirt and urine. He is mumbling to himself and other bystanders.

Staff report he arrived approximately 45 minutes ago and bought a bus ticket with cash. His bus is not scheduled to leave for another hour. Station staff became concerned when they saw him fall down a flight of stairs. He did not appear to loose consciousness but other details of the incident are sketchy.

When you approach and offer to help he swears at you and tells you to go away. There is a strong odor of alcohol on his breath and person. He says he does not hurt anywhere and does not need your help, he is simply waiting for the bus. He is rather ignorant, uncooperative and generally unpleasant to you.

He is ambulatory and walks without staggering. His speech is coherent and he appears orientated to person but refuses to answer questions regarding place, time and situation. He will not tell you how he received the injury to his head.

Visual examination reveals various abrasions to his forehead and face. His right eye appears swollen and bruised. His radial pulse is strong and regular. His pupils are equal and reactive to light, but sluggish. It is difficult to complete a primary survey due to his uncooperativeness, but everything appears normal with no signs of trauma other than to his face. He refuses treatment and transport.

1. This patient should be transported. A) True B) False    

2. Causes for the belligerent, slightly confused behavior of this patient could be: A) alcohol B) head injury C) hypoglycemia D) all of the above E) A and B only    

3. There is mechanism to suggest a head injury for this patient. A) True B) False    

4. This patient can be arrested under the mental health act. A) True B) False    

5. A peace officer could arrest this patient for: A) refusing your treatment B) swearing at a medic C) being drunk in a public place D) all of the above 

6. Documentation on a cancelled call should include: A) assessment findings B) your attempts to transport C) instructions given to the patient D) all of the above E) A and B only 

7. The P.C.R. for a cancelled call should include: A) a signed waiver B) vital signs C) signature of witness D) all of the above    

8. Because you have assessed this patient you may be held accountable for the outcome. A) True B) False    

9. Patients have the right to refuse treatment even if a competent medic determines they require it. A) True B) False    

10. A subdural hematoma develops: A) very rapidly B) outside the dura mater but under the skull C) beneath the dura mater but outside the brain D) within the brain tissue itself    

11. Cerebral edema: A) is swelling of the brain B) is the most common and serious complication of head injury C) becomes worse if there are low oxygen levels in the blood D) all of the above E) A and B only    

12. The most reliable sign of a head injury is: A) deteriorating vital signs B) unequal pupils C) changes in the level of consciousness D) none of the above    

13. ‘Raccoon eyes’ refers to: A) bruising behind the ear B) one blown and one constricted pupil C) bruising around the eyes D) none of the above    

14. You might be successful in transporting this patient by: A) explaining the situation and your concerns to the patient B) involving the police officers C) threatening to tie the patient to the stretcher D) all of the above E) A and B only    

15. Potential reasons for confusion in a patient include: A) seizure B) C.V.A. C) drugs D) hypoxia E) all of the above    

16. While you are attempting to reason with this patient his daughter, who appears concerned and competent, arrives on scene. You should: A) keep her away from the patient B) suggest she take the patient home with her C) explain your concerns and get her to talk to the patient. D) help the daughter put the patient in her car for transport.    

17. Contacting medical control when a patient refuses transport may: A) relieve you of all legal obligations. B) convince the patient they need treatment C) show you attempted all options. D) all of the above E) B and C above 

18. A patient who is under the influence of alcohol is not considered competent. A) True B) False    

19. A patient who is disoriented to place, time and situation can still be considered competent to make medical decisions for themselves. A) True B) False    

20. You can be held accountable for the outcome of a call once you have: A) been dispatched to respond B) approached the patient C) touched the patient D) taken vital signs and completed a primary survey.    

21. All patients who are assessed should be transported. A) True B) False    

22. In the early stages of I.C.P., one can expect: A) a decrease in systolic pressure B) a widened pulse pressure C) an increased diastolic pressure D) none of the above    

23. Treatment for this patient should include: A) positive pressure ventilation B) close monitoring of mental status C) glucose D) all of the above    

24. Brain injuries can be caused by: A) trauma B) blood clots C) hypertension D) all of the above    

25. Ways to improve your effectiveness in these types of situations include: A) developing good communication skills B) developing working relationships with local police C) knowing your service ‘s procedures for refusal of transport calls D) all of the above 

Please keep in mind the answers to these questions are to industry standards and may not necessarily be correct according to local protocol. If there is any discrepancy between these answers and local protocol, please follow the protocol for your area as set out by your Medical Director.

Heather MacKenzie-Carey is the Vice President of Turning Point Group Inc.— an Emergency Management consulting firm—and manages its Calgary office.

Heather has nineteen years experience in the Health Care Industry as an emergency practitioner, educator, and consultant. Heather has worked in public, private, rural, urban, Mountain Park and multidisciplinary clinical settings. Heather has been an educator/facilitator for the Aberdeen Hospital, Jasper School District, and the Southern Alberta Institute of Technology.

Heather has graduated from Dalhousie University with a Degree in Health Education. She has a diploma in Paramedicine from the Northern Alberta Institute of Technology, and a Certificate of Social Work from the University of Waterloo. Heather is competing a Masters of Science in the Study of Risk, Crisis & Disaster Management from the University of Leichester.

Heather has been widely published in the areas of prehospital medicine, crisis communication, and emergency first aid. She publishes regular columns for the Canadian Emergency, has developed various guidebooks for Quick Books Publishing Ltd., and produced distance delivery curriculum for the Southern Alberta Institute of Technology.She can be reached at geomac@cadvision.com or www.turningpointgroup.com.

This Article is reprinted by permission from the author (Heather MacKenzie-Carey) and the Canadian Emergency News. It originally appeared in the October - November 1999 issue (volume 22, number 5).