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Reasonable Accomodations

post #1 of 16
Thread Starter 
It was a little thing that became a big thing that then snowballed into a much larger mountain than the one I patrol on.

We were called to a case. A woman had fallen on our bunny hill and was complaining about a painful shoulder. We arrived on the scene and found the woman in a great deal of pain surrounded by three (male) members of her family. She was laying on the snow and we immediately started treatment. The problem? She was a Muslim wearing a hijab, and her male relatives did not want men touching her. At that particular time, there were no women patrollers available, so we continued in spite of the fact that her relatives were becoming visibly angry. Due to the sensitive situation, we did not do a secondary exam, and when we attempted to transfer her into the toboggan, she screamed, even though there was no movement of the injured area. We stopped, and asked again if there were any other injuries, and it was only at that time that she told us that her hip was worse than her shoulder.

At that point we said f**kit and over the objections of the family, we did an entire secondary exam, immobilized her from head to foot and brought her into the clinic. At this point, the ambulance was about three minutes out and the patient began choking under the cervical collar. We checked, and there were no obvious reasons for it, so we administered oxygen and finally, ambulance arrived. As there was no improvement in her breathing, the ambulance techs made the decision to remove the cervical collar (our protocol forbids this) whereupon they found a 2 1/2 inch hajib retaining pin was being driven into the side of her neck. Off came the hijab, on went the collar, and off to the hospital went the woman and her relatives. (without a thank-you, I may add)

As a result of all of these fun and games, we have had to develop a policy to cover this type of incident. It states (and I do not agree with a part of it) that in the event that a person wearing a hijab needs a cervical collar the patient must remove it herself, or she must clearly state that she wants the patroller to remove it for her. If it (a hijab) is not removed, we are supposed to stop treatment until it is removed. We are not allowed to place a cervical collar over a hijab under any circumstances. Personally, I do not agree with the stop treatment until removed part.

My question to you all: Do you have a policy covering this type of incident? We are feeling mighty lonely on this one, and we would love to know if this problem is in any way common, and if so, how do you handle it?

Dean.
post #2 of 16
I would assume that your local EMS system or trauma center would have that sort of protocol already set up. Why reinvent the wheel??

I understand your reluctance to agree with the policy, but it is still the patients right to refuse treatment. In this case refusing to remove the garment is essentially refusing treatment, thats their perogative.

If someone identified themselves as having a religious belief contrary to your protocols, how do you handle that??

We also have the policy of not removing a collar, once on, that does not mean that a parent or guardian or even an adult patient has to abide by that policy if they choose otherwise.
post #3 of 16
Dean, I can't help but feel that there may be some other underlying issues that ruffled your feathers at this scene.....maybe I'm wrong (and I hope I am), but does the fact that they were Muslim have anything to do with your feelings about this situation?

skier_j hit the nail on the head. Patients have the right to refuse treatment. They also have the right to yank the collar off anytime they want. Protocol says that "we" can't remove it once it's been placed on the patient. I am curious what you found during your assessment that made you decide to place a cervical collar on this patient?

I think the bigger issue here is the treatment of someone with a language barrier and someone with religious beliefs that differ from ours.

The fact that there was a "2-1/2 hijab retaining pin sticking into the side of her neck" raised my eyebrows too.

I'm not criticising your treatment of this patient at all. I am pointing out things that many patrols may deal with and should be aware of when dealing with people from other countries, religions, beliefs, or whatever.

This was a fantastic post. I hope this discussion continues and people come up with some good ideas on other ways this situation could have been handled or maybe good ways to prepare for situations like this.
post #4 of 16
We had an injury involving a Christian Scientist with a boot top fx. They do not believe in our medical care system. They allowed us to apply a splint, but refused further medical care. You have no choice so long as they are conscious.
post #5 of 16
I think Dean's point is the frustration of the insane state of emergency treatment. What if nothing is done in seeming deference to one's desires and the outcome is poor or disastrous? If you don't want help...don't call for it.
post #6 of 16
Quote:
Originally Posted by skiersjp View Post
We had an injury involving a Christian Scientist with a boot top fx. They do not believe in our medical care system. They allowed us to apply a splint, but refused further medical care. You have no choice so long as they are conscious.
That is correct. Patients have the right to refuse treatment. Although we would love to help them, we have to respect their rights.

Quote:
Originally Posted by flaskier View Post
I think Dean's point is the frustration of the insane state of emergency treatment. What if nothing is done in seeming deference to one's desires and the outcome is poor or disastrous? If you don't want help...don't call for it.
I agree with that frustration, but again, if they don't want our help or want limited help, that's OK. It's commendable that you want to help them, but it's still their right to refuse treatment.

They patient and/or family members may not have called for help. It may have been a by-stander that heard her crying out in pain that called for the patrol.

In any case, as well as we are trained to respond and act during emergent situations, we still need to remember that the patient gets to call the shots (within reason) if they are conscious and over the age of 18. No matter what, we have to obtain consent, whether it's direct or implied.
post #7 of 16
Thread Starter 
Quote:
Originally Posted by mnskibum View Post
Dean, I can't help but feel that there may be some other underlying issues that ruffled your feathers at this scene.....maybe I'm wrong (and I hope I am), but does the fact that they were Muslim have anything to do with your feelings about this situation?
Reasonable accomodations have become a sore spot here in Quebec. It all started started when a conservative Jewish school asked the local YMCA to please put curtains on the windows and to close them when there were women's aerobics classes. The curtains were installed, but then the report hit the media. The resulting controversy ended up forcing the Y to remove the curtains, and the Jewish students had to install something over their windows. It snowballed after that, then it hit our little hill. If I seem a bit put out, well, it was because of how this little problem became such a bit deal. As for me personally, I have no problems if someone wants or refuses treatment, and I have no problems if you are black, white, brown, a purple dinosaur, christian, jewish, muslim or even if you are a firm believer in George Bush and the little Green Men!

Quote:
Originally Posted by mnskibum View Post
skier_j hit the nail on the head. Patients have the right to refuse treatment. They also have the right to yank the collar off anytime they want. Protocol says that "we" can't remove it once it's been placed on the patient. I am curious what you found during your assessment that made you decide to place a cervical collar on this patient?
She was complaining of pain in her shoulder, then her side, then her back, then her legs, then we had enough and did the whole treatment. Her English and French were both ineffective for communicating the exact nature of her problems, so it was kind of guesswork. In the end, she was totally unable to walk, so we decided not to take any chances. She almost lost consciousness before we got her into the clinic.
The problem was that she never actually refused treatment, but her family was continually objecting to what we did without ever asking us to stop. As it was the first time that this situation had ever come up, we were kind of confused about the right course of action. If it were to happen now, we would lay down the rules and tell the family to shut up, and ask the woman what she wants. I was not there for the beginning or the end of the case, but I was told that she objected to the removal of the hijab. In the end, it was the hijab pin that caused a lot of the problem, and this is what made us decide that failure to remove hijab = refusal of treatment. It is a tough call, but I would have removed the hijab right away had I needed to put on the the collar.

Quote:
Originally Posted by mnskibum View Post
I think the bigger issue here is the treatment of someone with a language barrier and someone with religious beliefs that differ from ours.
According to every muslim with whom we have spoken, (including the local imam) we should have removed the hijab right away! I had already heard this, which is why I would have taken it off. But due to the delicate nature of the situation, we tried to 'offend' as little as possible, and that is what landed us in trouble.

Quote:
Originally Posted by mnskibum View Post
The fact that there was a "2-1/2 hijab retaining pin sticking into the side of her neck" raised my eyebrows too.
It was not sharp enough to pierce skin, and it was not being pressed perpendicularly into her neck. The base of it was laying across her collarbone and the tip of it was pressing into her carotid and throat, making it extremely uncomfortable. We could not see or feel it because it was inside the folded material of the hijab.

Quote:
Originally Posted by mnskibum View Post
I'm not criticising your treatment of this patient at all. I am pointing out things that many patrols may deal with and should be aware of when dealing with people from other countries, religions, beliefs, or whatever.
We try, we try. At our little hill, we have busloads (literally!!) of Chinese and Mexican tourists, Arab families, and so on who come to try skiing for the first time. Most of the time, it is a pleasure, but sometimes we do have.... incidents. This was the first one involving a female muslim.

Quote:
Originally Posted by mnskibum View Post
This was a fantastic post. I hope this discussion continues and people come up with some good ideas on other ways this situation could have been handled or maybe good ways to prepare for situations like this.
post #8 of 16
have you checked with the local EMS system for their input?? seems like it is not just Ski patrol related, why not expand the circle of knowledge??
post #9 of 16
Glad I read this thread. I don't think I'd have suspected there would be a large pin holding the hijab together around her neck. Now I know. Either way, I think my inclination would have been to untie (unclip, whatever) the hijab, put the collar on and then re-tie the hijab under the chin of the collar if she/her family indicated that she really didn't want it removed. But that's easy to say sitting at my desk rather than in the snow in the heat of the moment. I probably wouldn't have mentioned anything about my religion either.
post #10 of 16
Thread Starter 
Quote:
Originally Posted by skier_j View Post
have you checked with the local EMS system for their input?? seems like it is not just Ski patrol related, why not expand the circle of knowledge??
I will as soon as I see them. We have not yet started patrolling, although it looks like we will be opening this weekend. Can't wait!
post #11 of 16
I'm suggesting that if you had one incident at one small hill during one winter. The local EMS crews stand a very good chance of having dealt with that exact situation more than once. (not the exact injury) and most likely have a protocol in place already.
post #12 of 16
For those Monty Python fans:

Patroller1: Sir, I need to put this collar on your neck.
Patient: I'm not dead yet. You don't need to put that on. I'm ok.
Patroller1: No you're not. You are hit a tree and were knocked unconcious.
Patient: I'm feeling much better.
Patroller1: Sir, I don't recommend it. Your back and neck are twisted in a really nasty way. I need to put this collar on you for your safety.
Patient: I think I'll stand up now. Really, I feel much better now.
Patroller2: <smacks patient on the head with a ski pole, knocking him unconcious>
Patroller1: Right, thanks. Now let's get this collar on him.
post #13 of 16
Thread Starter 
Quote:
Originally Posted by eblackwelder View Post
For those Monty Python fans:

Patroller1: Sir, I need to put this collar on your neck.
Patient: I'm not dead yet. You don't need to put that on. I'm ok.
Patroller1: No you're not. You are hit a tree and were knocked unconcious.
Patient: I'm feeling much better.
Patroller1: Sir, I don't recommend it. Your back and neck are twisted in a really nasty way. I need to put this collar on you for your safety.
Patient: I think I'll stand up now. Really, I feel much better now.
Patroller2: <smacks patient on the head with a ski pole, knocking him unconcious>
Patroller1: Right, thanks. Now let's get this collar on him.
As one of the many who has had the great fortune to have seen 'Spamalot' on stage in London, I really really really like this one!
post #14 of 16
Interesting case.

FWIW, I work in a hospital with a significant Muslim population. While I don't know much about the religion, I know that there exceptions to the modesty rules when it comes to medical issues. I have never had a problem.
Of course in a pair of scrubs, it is obvious I am a medical professional. In ski clothes, It may be less obvious.

On an un-related issue: The policy of never removing a collar, or taking somebody off a board is worth looking at.
A: The hill is not always a good place to do a full spinal assement. It makes sense to stabilize the pt untill a good assesment can be done. Similar to manually stabilizing a spine untill you can do a good assesment- except more effective.
B: Pt's are dynamic. They change. The pt who could not be adequately assesed while cold and scared, may be become more reliable iinside.

HH
post #15 of 16
Well I've never wandered into the Patrol Shack here before!...

Anyone read White Heat by Wayne Johnson? He's a patroller at Park City and there's some interesting things in there about non-compliant patients that has nothing to do with language or religion.
Pay no attention to the whole "extreme" descriptions about the book since it has almost nothing to do with what is commonly referred to as 'Extreme Skiing'. Well unless y'all consider patrolling 'extreme'. Certainly could see the point...
here's a link:
http://www.amazon.com/White-Heat-Ext...8324199&sr=1-4
post #16 of 16
Many interesting comments above, here is my comment. The legal (age 18) responsible party has the right to accept or reject the proposed treatment. If the patient is unconcious that constitutes an afirmative to treatment.
Before proceding with treating a patient, an explaination should be given as to what the treatment is(will be) this includes the IPS, after which the required treatment explaination maybe modified to fit the findings. If the patient refuses the suggested treatment, have a "refusal of treatment" form signed, if they refuse to sign the form, get at least one additional witness the sign has to what has been refused.
In 25 years of patrolling I have only seen 1 time where the treatment was refused (the patient signed the refusal) after which additional witnesses were interviewed for the report.
Personal rights are very interesting.
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