Chemical Restraint & The Right to Refuse Medical Treatment (4/29/18)

Medic One Protocol is Unsafe : Revise the Protocol
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“The concept of a right to refuse treatment was built on basic rights to privacy, equal protection under the law, and due process.” — David L Sederer, M.D.

Index:

The Death Of Vaneesa Hopson

Local Action: Revise Thurston County EMS Protocol on Chemical Restraint, Contact Olympia City Council Member Jim Cooper

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The Death of Vaneesa Hopson

In the early morning hours of February 7, 2018 Vaneesa Hopson was forcibly injected with a sedative by EMTs, a practice called “chemical restraint”.  The EMTs thought Vaneesa should be transported, while Vaneesa did not want to be.  Vaneesa was able to fend off the restraint for an hour before finally being sufficiently restrained physically by police that an EMT was able to administer an injection of a drug, which according to EMS protocol and fire personnel statements was 10 mg Versed (the brandname of midazalom).  Very quickly she experienced respiratory arrest.  EMTs report they were able to revive her in the ambulance on the way to St. Peters Hospital.  At St. Peters, she died when her sister made the decision to take her off life support.

It was reported that officers wanted to detain her for a mental health evaluation.  But none of the first responders called the crisis response team that law enforcement in Thurston County are supposed to call for assistance when mental health is a concern, according to a staff member on duty at the time of the event.   The drug was administered without doctor supervision.

Why?

Vaneesa’s behavior that night indicated she may have been under the influence of drugs.  Given that possibility, what I find most alarming is that the warning for midazalom includes this statement:

Using midazolam with opioid medications (such as codeine, hydrocodone) may increase your risk of very serious side effects, including death.

Why are first responders even using this drug under these circumstances?  Why is this the drug specified in the Thurston County EMS Protocol for chemical restraint?  Why doesn’t the protocol include warnings about serious interactions with opiates at a time when we have a heroin epidemic?   Why doesn’t it require the involvement of mental health professionals who were on duty at the time of this event?   She was already physically restrained.  Why not just transport her without chemical restraint?

Why?  It makes no sense if you have concern for the health and rights of the person.  It makes sense if your concern is expediency and convenience of first responders.  But expediency is not an excuse for putting someone’s life at risk or violating their civil rights.

The Right to Refuse Treatment

All patients have a civil right to refuse treatment that is based on the right to privacy, equal protection and due process — and this right may be overridden only under specific conditions (Sederer 2013).  Involuntary treatment, usually a medication given by injection or by mouth, is warranted only in the case of an emergency, which is defined as “an imminent danger to self or others.”   Generally, the following critieria should be met:
1.  The treatment is necessary for safety and recovery;
2.  All efforts at voluntary treatment have been exhausted;
3.  Family and others have been engaged to help persuade the patient to accept care (and were not successful); and
4.  The benefits of treatment are likely to outweigh its risks.

In Vaneesa’s case, there was no medical emergency.  Family and mental health practitioners were not engaged.   And the medication they used has serious side effects if injected too quickly or when combined with opiates — when, as reported, responders thought she was suffering from a “mental health crisis and/or acute effects of substance use”.  The risks of treatment were too great to override her refusal of treatment.

Thurston County’s EMS Protocol is Unsafe

In our preliminary research in the wake of Vaneesa Hopson’s tragic death, we find Thurston County’s EMS Field Protocol for administering “chemical restraint (pages J-51 to J52) to be in conflict with warnings for the drug specified by the protocol, midazolam (10 mg), in the following ways:

  • Drug warnings state that midazolam should only be used under close medical supervision due to the risk of serious side effects, which include death and brain damage, yet the protocol allows EMTs to administer the drug without a physician’s orders.
  • We question that midazalom, a “potent sedative agent”, can safely be injected in the field given the drug manufacturer’s recommendations for “continuous monitoring of respiratory and cardiac function, i.e., pulse oximetry” and “immediate availability of resuscitative drugs and age- and size-appropriate equipment for bag/valve/mask ventilation and intubation, and personnel trained in their use and skilled in airway management.”
  • EMTs generally do not have the training level recommended for administration of midazolam.  Instructions state, “Midazolam should be administered as an induction agent only by a person trained in general anesthesia and should be used for sedation/anxiolysis/amnesia only in the presence of personnel skilled in early detection of hypoventilation, maintaining a patent airway and supporting ventilation.”  (Note anesthesiologists are physicians.)
  • Midazolam interacts adversely with many medications, including opioids, other benzodiazapenes, and blood pressure medications.  Yet the protocol does not call for screening the patient for possible medications they have taken.
  • Drug warnings state midazolam requires “individualization of dosage”.  The dose of midazolam may need to be adjusted considering the patient’s size, age, condition, and other medications they may be taking, yet the protocol specifies a single dosage for all patients.
  • Administering midazolam too quickly into a vein can cause serious side effects, including death, yet the protocol permits intravenous administration without physician oversight in possibly chaotic, distracting field conditions with “violent and combative” patients.  The protocol does not require involvement of the Thurston County crisis response team, which could de-escalate the situation.

  • Midazolam may harm the unborn baby of a pregnant patient, yet the protocol does not require asking the patient about possible pregnancy.

Revise the Protocol

Citizens Against Chemical Restraint calls for a moratorium on forcible medication to “chemically restrain” patients by first responders until safe protocols and practices are implemented.  We suggest a protocol that:

  • requires involvement of mental health and crisis response professionals and, if possible, family members,
  • requires oversight and consultation with a physician concerning the patient’s current condition,
  • specifies medications that do not have serious side effects when combined with opiates and other common street drugs and pharmaceuticals,
  • requires that safe, voluntary, and non-invasive methods are exhausted first. 

Event in Olympia, WA

Connect With Others

Make Your Voice Heard

The Thurston County EMS Council is under the Thurston County Board:  http://www.co.thurston.wa.us/medic1/

  • Action:  Write or call the EMS Council staff contact Fay Flanery with your concerns, (360)704-2784, flanerf@co.thurston.wa.us
  • Action: There are two EMS Council meetings per month and each allows time for “public participation” where members of the public are allowed to speak.
    • Operations: First Thursday 2:00 pm to 3:30 pm
    • Council Responsibility: Third Thursday: 3:30 to 5:00 pm

References

    

 

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