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We're accumulating a lot of clear x-rays and CAT scans at the local hospital. I'm thinking of asking the MC to call me to come see him BEFORE they ship him off by ambulance. Last night we spent 6 hours in the busy ER in the hallway between a young heroin addict with serious medical issues and an older cocaine addict who kept wandering around touching all the other patients. During all that time, I was trying to keep my husband lying on a hospital bed because he wasn't in any pain and couldn't remember from one minute to the next where he was or what was happening. Any advice?

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My mom would slide to the floor when being transferred from bed to wheelchair and the SNF nurse would send her to ER. So I had suggested as long as she didn’t hit her head or present any pain to not send her out. ER visits were an eight hour deal. It would take a few days for mom to acclimate herself and realize she was back at her facility.

So at the Care Plan meeting we agreed that if they could treat mom on site, UTI’s, etc, she would not go to the ER.
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They are covering their butts. In the 4 months Mom was in the AL, they sent her to the hospital 4x. I talked to them about it. They said she claimed pain. I told them don't they have pain when they fall? And a Dementia patient seems to express pain like a child. You know, one little scrape and they are dying. I told them to call me first. I lived 5 min away and have an RN for a daughter. I would determine if she went or not. Unless, she hit her head, then she went to the hospital.

I was told when Mom went to skilled nursing that they do not send residents out every time they fall. If they hit their head, yes, out they go. Otherwise, they observe the person.

I know, its a catch 22, damned if you do and damned if you don't. What if this fall "is" serious. I took on that responsibility. They do not go with the resident and I was the one that sat there, in an uncomfortable chair, for 3 to 4 hours.
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WearyJean, I don't know what the protocols and standards are for hospital examination after a fall, at a memory care facility, but I do believe that it's the best way to be certain there aren't any hidden issues.

An example:   my father, in his late 90s at that point, fell down the cement porch steps one day in December; the church friend who was with him took him to Sunday services, and another congregant put bandaids on his skinned leg.  No one told me. (This was a major issue as he aged; they didn't feel I needed to know as they felt they were qualified to care for him.)

A few weeks later an issue arose which required ER treatment.   I saw the skinned knee, covered with a bandage, which was being overgrown by skin, trapping the bandage against his leg.    The ER doctor declined to debride the wound.   Since I didn't know until then that he had fallen, I hadn't made the necessary efforts to have it debrided. 

We had a podiatric appointment in a few days, during which I was trying to find someone (medical, not a church acquaintance) to take care of the wound.   I asked the podiatrist, who was one of the top doctors we were seeing if she could offer some recommendations.  She  knew how to debride, and she did, taking care of something that never should have gone as far as it did.

So, I would opt for a ER visit just to make sure everything is all right and there's nothing hidden than might show up later, in a more complicated state.
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help2day Oct 2021
"The ER doctor declined to debride the wound." Unbelievable! I would have insisted while he was there for the doc to take care of this. A bandage growing onto the skin and he refused? I would have raised holy hell.
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A SNF has to have at least one licensed nurse in the building at all times. Depending on the facility protocols, the level of apparent injury, and the other medical conditions of the resident, the MD who is responsible for the patient will tell the nurse to send patient to ER or give medical orders for assessment and treatment. Important to discuss at care plan meetings and obtain your state's version of MD orders for care at end of life. (Covers DNR but also how aggressively to treat and where to treat life ending situations.)
An ALF is housing with supportive services. They might have a licensed nurse in the building for some parts of most days. The staff are unskilled, and cannot judge if patient is injured or not. So, 911 to the ER is the default plan. You may be able to make specific arrangements for your resident if you live nearby, etc.
ALFs prefer to have any resident with falls placed on hospice, so that if resident dies at facility, there is no implied liability for failure to care by ALF.

Knew one place where 2 residents in the first 6 months they were open died of head injuries as not sent to hospital..or checked hourly. After that, even a suspected fall went to ER for about 3 years.
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Invisible Oct 2021
That might be what has precipitated the current discussion that ALFs need more regulation.
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Seems to me the place needs to focus on why there are so many falls to begin with. Perhaps your husband needs to be in a wheelchair now.
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freqflyer Oct 2021
My Mom use to tumble out of her wheelchair. The nurses had a difficult time trying to keep her seated as Mom could not longer stand up without falling. The nurse even tried to use a seatbelt, but my Mom was the master of unlocking a seatbelt [she would be in our car, a mile from home, and we would hear that familiar metal sound of her unlocking].

Eventually the Staff used a pillow under her legs and that worked for awhile, as my Mom would spend time trying to remove the pillow.
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You need to review the protocol from the facility about falls. This is probably part of their protocols. They need to have every person who falls assessed for injuries by a qualified healthcare professional.

While you are talking about falls with the administration, ask about their protocols for protecting people at high risk for falls. Every facility with population at risk of falling will have one. See if it includes: increased observation, low beds, mats by side of bed, call bell within reach, frequent toileting...
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Interestingly, no one blames the ERs for taking as long as they do now just to assess the patient. These long hospital waits started pre-Pandemic.

My Aunt in her 90s was in the Skilled Nursing part of a retirement community in Florida when she fell on a Friday night while they were helping her shower. No one notified our family (her remaining family and emergency contacts). However, a local friend who would visit her often was contacted and told her legs just buckled; it was a minor thing. He was on his way out of town for the weekend and did not check on her nor contact me. On Monday he did visit her and called me to let me know "she wasn't right". I contacted the SN director who said the only way to have her seen by a doctor (who only came on Wednesdays) was to send her to the hospital in an ambulance and only family could initiate that. She had a DNR. I sent her to the hospital. She passed away there that night.

My father fell in MC also on a Friday and they tested him for mild UTI before opting to send him to the hospital "to get stronger" as there would would only be a nurse on call over the weekend in MC. He was given fluids/antibiotics and told he could return home that same day but the MC asked them to keep him over the weekend. The hospital gave him too much fluid and he took a turn for the worse so the hospital stay ended up being a week before they released him to Rehab. This was his 3rd go around with fall/hospital/rehab. He asked me "How much longer do we have to go through this?" That was the last time.

I didn't want Dad to die in the hospital like his sister. Guessing my Aunt is still mad at me.
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Mom is starting to 'fall' on kind of a regular basis. She swears she doesn't FALL, but everything goes black and she 'gently slumps to the floor'.

I think that is the very definition of 'fall' but I could be wrong.

She lives with YB and he refuses to take her to the ER. I'm done arguing with him about this. She is 91, frail as a little bird and has a lot of pains and aches after these 'slumps'. YB thinks he can dx mom's injuries. Currently, from her last 'fall' she cannot move her left arm without serious pain. I think that's worthy of a checkup but neither she nor YB do.

If mom were in a NH I would WANT her to be checked out. yes, it's a time consuming thing, but she often has UTI's and they make her dizzy. She also doesn't WANT to go to the ER and I don't blame her, but I know one of these falls is going to be the last one she takes at home.

In our state, I believe it's required that a person who falls be taken to an ER unless a dr/pa is on site and can evaluate.
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MaddieMae Oct 2021
If your mother is blacking out for ANY reason, she needs to be seen by a physician immediately. This is called Altered Mental Status and if the cause is unknown is considered an emergency. There are many factors that can cause AMS—some deadly and some minor. By refusing to take your mother in for evaluation, your brother is committing elder abuse. As an EMS professional, I find your post very concerning.
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Talk to hospital Social Worker about getting him into nearby facility. Take the time to tour place while he’s in hospital. Once he’s in there, try & avoid ERs ..After short term rehab, talk to Medicaid office about long term care. If there’s a lot of $$$ involved, see Elder law Atty. Good luck & hugs 🤗
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I would find out their protocol and see what changes they are able to make for your husband at your request. Is he on hospice or could he be? I wonder if that would make a difference?

I think it is absurd to send someone to the ER JUST because they fell. My MILs sister used to get mad when she didn't call 911 when she fell. Then I'd go sit with her for hours and hours cuz it takes bloody hell forever at the ER even when they are NOT busy and she would whine and complain about being there so long. We finally got her trained that 911 was for actual emergencies. If you hit your head, are bleeding profusely or in major pain (after a few minutes not from the initial fall), then call 911. Instead, call us and we'll help you evaluate if medical intervention is needed.

It would be nice if MC could do something like that too! There is way too much cover-your-butt type of decisions made for patients. They are often expensive, time consuming and unnecessary.

Definitely let your wishes be known ASAP. Hopefully something can change. Also agree with other posters to brainstorm with facility to see if they have any ideas on WHY he is falling and if there is anything that can be done to help in that department.
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Ok, so, I'm sort of an 'expert' on falls in AL and Memory Care in general since my soon-to-be 95 y/o mother has taken 80 of them over the past few years (that we're aware of). EIGHTY. 40 falls since moving into Memory Care in June of 2019. Here's how they deal with all falls their residents take: the nurse assesses the resident; did they hit their head? IF they hit their head, an ambulance is called and an EMT does a further assessment and off to the ER they go. If they DID NOT hit their head in the fall, then the nurse does a full body assessment to see if there are any skin tears, bruises, bloody scrapes/cuts, etc. The resident is asked if they're in pain as well. The vitals are taken; if all is well, no further action is taken but the POA is called on the phone to be made aware of the fall. The resident is watched for the next 24 hours to make sure they're ok. That's it. IMO, that's the proper way to handle a fall; otherwise, I'd have taken 80 trips to the ER with my mother for NO GOOD REASON. These ER trips would have been traumatic for her and for me, and they'd have been expensive to boot. Find out what the policy is EXPLICITLY at your DH's MC and go from there. If he's prone to falls and their policy is to send the resident to the ER EACH and every time, regardless of whether they're hurt or not, I'd move him out of there b/c that policy is ludicrous IMO. It's the CYA principle taken to ridiculous new heights!!!

A few times, my mother complained the next day of pain in her arm or leg or whatever, so her PA ordered the traveling xray team to come to the MC to take an image; nothing was ever broken (believe it or not) in any of her falls. Early on in the AL, she broke a couple of ribs and a sternum bone or two, but she never pressed the call button for help, so the staff didn't know she'd fallen (she was able to get herself back up alone). During an admission for pneumonia, she had a CT scan and that's when the broken bones were discovered, in various stages of healing! Even if they were discovered during the actual fall, however, nothing could have been done for her in the ER b/c those bones aren't set in any way and just left to heal by themselves.

Good luck; I know how awful the whole situation is when a loved one falls.
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WearyJean Oct 2021
Thank you Lealonnie. I always appreciate your wise advice.
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I’m not sure if different states do it differently, but when my dad 90yr. old) fell in his MC facility the nurse on site would come check him out and determine whether a trip to the hospital was necessary or not. She’d call me to tell me what happened and 9/10 times would say he’s got a skin tear, or small bump but is going to be just fine. Dad reacted better with the one nurse and caregivers he knew. It might get just be a facility trying to cover their fanny because there are some looking for a lawsuit? With covid so prevalent, ask the director what’s possible there. The falls can happen even when help is right there. It’s a tough situation for sure. Good luck!
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That's probably their protocol when there's a fall.

You can die from bleeding to death from a broken hip and of course you could just be bruised or have a hair line fracture.

Going to the ER is an awful experience especially with dementia.
Nor only is it very hard on the person bur you could actually catch something there and get sick.

I think I would rather go check my husband out myself and not go unless he is feeling pain or showing any signs of distress.

I think I would just spend the night with him so 8 can keep an eye on him and see how he is the next morning.
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I can't imagine after a fall allowing a spouse or family member to make that kind of decision. Its almost like allowing you to make the diagnosis after a fall. Like it or not, they would have a legal liability and open themselves to lawsuits. A family member could claim they weren't timely informed or were misinformed. I suppose you could allow him to be transferred to the hospital and go there yourself only if they find a problem.
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I had the same issue with my dad. It seemed to depend on who was working at the time whether they followed procedure and shipped them out for X-rays. I assume they’re just trying to cover their butts to avoid a lawsuit. If you live close to the facility I would definitely ask them to let you see your loved one and make the decision yourself.
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In a facility they have to be sure that there were no serious injuries.
An unseen fracture, a concussion, brain bleed...
And what was the cause of the fall? Was it a BREAK then FALL?
I am sure for liability reasons they would not want to "waste time" contacting you then possibly waiting for you to get there before calling 911.

When my Husband would fall at home I would call for a "Lift Assist" and they would ask if I wanted him transported and I always said no. They never insisted.

You could find out if your husband is eligible for Hospice. Once on Hospice THEY become the 911 and a call would go to Hospice and they would probably decline the transport to the hospital. That is not to say that Hospice would always refuse transport to the hospital if they think it is serious enough to order it they would. (Chances are if he were admitted he would go off Hospice and then Medicare or Medicaid would be the coverage then once discharged he would go back on Hospice. Can not have 2 agencies billing at the same time)
Also if he has a POLST or DNR they may not transport him either. Check with the facility to determine their policy on that.
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lealonnie1 Oct 2021
This comment debunks the myth that elders 'never fall at home'; they do indeed. They also fall at AL, MC and SNFs b/c it is literally IMPOSSIBLE to prevent an elder from falling, period. My mother's MC is like a fortress; they've taken every possible precaution to prevent her from falling, but falls continue to happen for a variety of reasons: she has no core strength; she has no strength in her legs; she has bad neuropathy; previous to her becoming w/c bound she had poor balance that NO amount of PT/OT helped with. She also pays NO attention to where she's going or what she's doing, which was an issue prior to the dementia getting bad. So for anyone to say it's the MCs fault for the falls is sadly mistaken. It's nobody's 'fault' for these falls; it's old age's fault, in reality!
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We have had a few of those falls/ER trips also. But my mom starts up with the delirium so fast in the hospital setting, I had a sit down with the director and Memory Care manager and we came to the agreement, that minor falls that they saw, if her vitals were stable, and she was not in obvious pain didn't have major bleeding, didn't hit head, the on-site nurse would access and they would monitor, not call the ambulance for transport. They call me to inform.
Unattended falls, instead of auto transport would be assessed by EMT. They let me talk to EMTs and I make the call to transport or not.

Now she is on hospice, and they are called to assess if necessary; haven't seen how that goes yet, she hasn't had a fall since we started hospice recently. She does have a DNR.

Its not that I don't want her treated for an acute injury, but the whole ambulance ER thing is so traumatizing for her, that it's often not in her best interest. And one time she was transported for an unattended fall, because she was complaining about her leg, and I was concerned about her hip. Hip was fine, but she had broken ribs!
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The question here should be "Why is he falling so often?" Voice your opinion clearly to the administration about ER visits and why. Gracie61 has some good suggestions about this. Be firm that you expect the MC to take all available steps to keep your husband from falling - whether it be contoured bed pads, floor pads, PT/OT, neurological evaluation, etc.
In pursuing this line of questioning you and the MC can find ways to avoid/decrease these falls in the first place.
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They are protecting themselves from being sued by doing this. They need to “CYA” so to speak. But I agree with a previous comment asking why are there so many falls? Perhaps his doctor should be looking into his equilibrium and he may benefit from PT or OT to strengthen his balance and evaluate what’s making him fall so easily.
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Sarah3 Oct 2021
And this debunks the idea my friends sibling had that they should put their mom into assisted living to prevent falls. Eye roll patients fall all the time in medical centers, skilled nursing and especially assisted livings
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We lost track of the number of times Papa fell, I stopped counting after fall #52 - he had Parkinson’s, which is a “Fall Down Disease”.

The nursing home suggested that they thoroughly exam him and then call us with their findings and ask us if we wanted him transported.

We would have lived at ER! Ask your nursing home to set up the same system.
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I live in assisted living and have fallen. I am not completely sure but it is a safeguard just in case something broke or is damaged - and liability. I do understand that the patient can refuse to go - but I would assume this depends if they are mentally competent. I have fallen twice - once I was so groggy being forced to get up to early in the morning for an appointment. I tripped, hit the table and broke the leg and slashed the inside of my mouth to shreds - l/8" more and NO TEETH. I was lucky but I agreed to go to t he hospital as I needed my mouth stitched - I was red with blood. Another time my but slipped off the wheelchair and I ended up on my butt on the floor and could not get up. 911 came and lifted me up - I was fine. I said NO to the hospital.
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lealonnie1 Oct 2021
Why would an AL have to call 911 to have you lifted up from the floor when they have an entire staff there to help you up???? While living in AL, my mother fell 40x and not once did they have to call 911 for assistance in getting her up!! Same thing in Memory Care AL; having fallen 40x there, the staff helps her up each time. In fact, at the AL/MC I worked at, they were expressly forbidden to call 911 to help lift up a resident who'd fallen as they were responsible to take care of those matters themselves in house and not bother 911 with such matters. Of course, they could call 911 if the fall was serious & required an EMT to come look at the resident, but not to just pick them up.
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This is likely their facility procedure due to legal (and emotional) liability and standard of care.

Falls can be fatal and damage can only be fully assessed by hospital personnel.

You can skip the ER if you care for him at home.
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Probably a liability issue for the facility. On the other hand, better to get the scan and know for sure there isn't a break somewhere.
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WearyJean: Imho, it is liability issue for the facility if they were to NOT send your LO to the hospital ED via EMS, think potential brain bleed and other serious implications that could arise. Also, I will address your point about other hospital ED patients and that is you don't control which other patients are awaiting care. You could simply state to the nurse "the touching" (of your LO).
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I would certainly get them to call you before having him taken to the hospital, but they may be complying with their insurance and not have a choice. Perhaps you can sign a waiver so they contact you and the decision is yours, but presumably you will want to see him before you decide which will take some time if he has damaged himself so think about the wording and when they should decide and when you should. If they pick him up and he can walk around with no pain (with a walker if he usually uses one) then that would seem a reasonable time for them to contact you first - it won't mean he hasn't damaged something but it probably isn't an emergency.
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My husband is in AL, but was encountering same...because it's their policy-which I asked for and  they never produced.  HOWEVER, when I reminded them that he is a no code, they were more ameanable if I agreed to keep a copy of POA on file with those directives.  There is a copy on file in the office now as well as on his fridge.  Our verbal understanding is that unless he's in pain or they see bones or cant manage bleeding from a minor wound, he is not to go to the hospital.  The risk to benefit ratio, especially with COV doesn't warrant.  His PCP agreed.  So far so good.
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The facility is responsable for limiting his abilities. The E.M.T. is responsable for deciding if transport is needed.
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My grave concern is why he is falling to begin with. As others have said, his geriatrician needs to check his body and meds, and refer for PT if it warrants.

The AL needs to have alarms on his bed and wheelchair to alert them if he is getting up.

More assessment and more monitoring seems in order to prevent falls, rather than limit care when he does fall.

I imagine the AL is required to call EMS, who then assess and decide to transport or not. But, with dementia, the assessment would be extremely limited and they would almost certainly decide to transport because he can't accurately answer questions to rule out a brain injury.

It strikes me that you were with him at the ER for 6 hours and did not choose to check him out and take him back to AL. You could have signed to check him out against medical advice. Medical professionals are obligated by their license to rule out injury and once the EMS is called. The AL has policies, that you signed, when you placed your husband. Please let these policies and procedures work smoothly, and let the professionals do their job - until you sign to take him out against doctors advice. The professionals need the liability coverage that the P&P and medical protocols provide to ensure good care for everyone.

That said, all of your medical documents should be filed with both the AL facility and the hospital where he would go for care. You can have a DNR and a Medical Directive filed. However, check with the hospital about if the ER has to observe them. In my state, once EMT is called, full measures will be taken to save his life. I believe that is true for the ER as well. The implication is that if a patient lands in the ER they are to work to save them. Period.

This is where hospice can be helpful. Hospice will not call EMS and directs families to not call EMS - for the above reasons. If he is eligible for Hospice, it is time for a new placement.
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WearyJean Nov 2021
Thank you, MAP. Good information!
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Once we called 911 and my uncle went off in the ambulance, I felt like he fell off the face of the earth! It took hours to reach anyone who could tell me where he was and the status of his condition. Of course, COVID is a factor in these cases, but after 19 months of medical facilities handling the disease, its time they are held accountable for these kinds of breakdown in communication. A doctor was assigned to my uncle's care who never called me, not even once and had no phone number for me to reach him. When I called the hospital, it took 15 minutes for anyone to figure out who the doctor was I had asked for and, again, he never returned my calls. My uncle had already been in assisted living but instead of sending him back there they sent him to the worst "nursing" home I've ever seen in my life! I felt like we were living in a third world country when I finally got in to visit him!!! They didn't shave him for 4 days and wouldn't bath him because he refused to let a woman undress or watch him, even though they had male nurses. I finally got him out of there after 5.5 days! Again, the doctor never called me even once. I've been waiting for the survey to come so I can slam that facility and let the world know how awful it is!!! I feel so sorry for anyone who is in a place as bad as that.

He didn't understand where he was or why and my husband and I realized he didn't have to be there; we could just take him home (back to his regular facility) without their permission. Once he was home again, he was much better mentally and we were able to get PT for him at his home living facility.

Medicare wasn't much help either. They took down notes about what I was saying but didn't seem to have any advice to offer. They said they'd get back to me in a few days. In a few days????!!? I couldn't wait "a few days" to get him out of there!

It is expensive to have your loved one shipped by ambulance but the liability issues are great if that's not done. Meanwhile, in your case, your husband was subjected to that cocaine addict touching people. EMTs are trained to move injured patients and are probably the safest way to transport them.

Not knowing exactly what the test results were for your husband, I'm not sure what to advise except that you are not forced to keep him in an unacceptable facility, although it may cost an ambulance ride to move him.

On the up side, he did receive the tests he needed and the recommendation for PT, if warranted is good.

In our case, I've learned the lesson not to just accept what we're told and not to agree to anything until. I fully understand the procedures. Also, I now insist on the names of the attending nurse and doctor and that I have numbers where I can reach them. I also know that I can remove him at my discretion, not theirs.
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