Alert and "Oriented"

We've all been there.
Talking to a patient who is not quite entirely processing what is happening, but is doing a really good job of faking it, trying to determine if they meet the legal criteria to refuse care and transport.

There are arguments about free will, the Cow Tipping of EMS (Kidnapping), when intoxication ends and inebriation begins, and vice a versa, but I have to wonder if we're setting ourselves up for failure.

I was reading back through some old archived draft posts from my Engine days and came across the following scenario I think enough time has passed to share and get your input.


PD reporting a woman is altered.


Altered?  Like how? it.

Woman found behind the wheel of a car in the right hand lane at a green light.  Conscious, hands on the wheel, vehicle in park.  PD arrives and she doesn't want to leave the car so we get called.

The Ambulance beat us in so I'm in backup mode on this one. She is constantly scratching her cheek and rubbing her lips.  She makes eye contact, tracks and answers questions clearly and I'm waiting for this younger Medic to ask the obvious question:

"Why did you stop?"

He takes a BP and a blood sugar, both in normal range for refusal, then asks some of the stupidest questions I've heard.

"Do you know what City you're in?"  Dude, your patch 2 feet from her face says "San Francisco."

She answers correctly.

"How many quarters in a dollar?"  What?  This is preschool level stuff.  Are we establishing alertness or getting ready for a pop quiz.

She answers correctly, giving a small look around the Officers and Firefighters assembled as if to ask "Am I being punked?"

"Who is the President?" And this is where I went from helping to primary.

"Hi Jane, I'm Justin, one of the Paramedics here.  I was just wondering...why did you stop?"

"I don't know. I was lost I think."

"Fair enough, where are you headed?"

"Anywhere I guess."

"Where did you start from?  Home?  Is it safe at home?"

At she answers this I see the PD Sgt step back and speak softly into his mic.  He's likely asking to run her as a missing person.

The ambulance medic stands from his knelt position and adjusts his glasses. "Well, she's A&O so a refusal will work."

That was many moons ago.  Here, now reading it again I'm amazed I didn't come over the counter Farva style at him.  I was much calmer back then I think.

There's a saying, "Ask a stupid question, get a stupid answer."  Don't default to the stupid questions your preceptor told you to use to clear the scene faster.  Ask your patients to answer two things at once that they haven't spent hours, months or decades learning.  Don't let your questions be easy to answer.  Challenge them, then assess their ability to process the question, create a response and give said response effectively.  Only then can we be sure that they "understand the risks involved with refusal of care and/or transport."

I don't care if they can recite the last 15 Presidents, know how many hay pennies are in $4.56 or where they are.  Can they understand what is going on and the options set before them?  Only then are they "oriented."