PRIMARY ASSESSMENT:
You and your partner remain calm and introduce yourselves and you say," I understand you've had some problems. We are certaintly not here to create any more for you, we just want to make sure you are ok. Are you feeling alright? Do you have any pain?, the witness noticed you had your head slummped over at the wheel, did you lose consciousness you think?" He replies, "no no I just rested my head on the wheel for a second", you see no bleeding, and his skin color is fine." I am sorry I got so upset, it's just been a really bad day". You note that the patient is aleart and breathing fine. He refuses stabilazation, but agrees to take his pulse. It is a little high but within normal.
SECONDARY ASSESSMENT:
You explain to him that you would like to do a physical exam to make sure he does not have any injuries. He becomes angry and says, " Come on, I'm ok.I don't need that", you ask him if you can take his vitals, he say's, "No no I'm really fine". Your partner discreetly calls dispatch to say, "Patient is refusing emergency care and transport. We will inform you of status shortly".
DOCUMENTATION:
You realize that you are not going to have any success in persuading him to accept care, you explain to him that before he leaves he must sign a refusal-of-care form. You prepare the PCR and the refusal forms. On the PCR you note that he hit his head and your initial findings regarding his alert mental status, his airways, absence of bleeding and condition indicating adequate perfusion. And that he denies losing consciousness.
You show the document to him and allow him to read it. While he is reading it you asks for a witness while he sings the documents. You suggest that he sees a doctor as soon as possible and if he feels dizzy or pain increases do not hesitate to call 911. Your partner contacts dispatch and states that the patient has refused treatment and transport. You unit is now clear and in service.
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