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Yes, you were wrong to protest it on principle, but you were not wrong to question it thoroughly on principle. I don't believe so, no. I believe that speaking with the pt about your concerns and with the doc if you felt it was appropriate was the right thing to do. But then, if it was truly the well informed pts wish, you should have taken him home. Yeah, you just don't know this yet. Somewhere in the paperwork was a paper signed by the doctor describing this pts medical need to be transported home by ambulance as opposed to private vehicle or taxi. The pts doc asked for it and your company was/will be paid for it. So do you then feel that the pt would have been better served by you and the EMS community had be been made to take a Taxi home? Long waits, embarrassing needs, perhaps unpleasant smells? A stranger and non medical professional to help him into his home and tuck him into bed? You're right, the pt IS going home, do you feel that we have advocated for him by making that journey as painful and embarrassing as possible? Do no harm is certainly the halo that surrounds our little profession, though being a pt advocate certainly hovers up there right next to. Your patient wanted to go home. You were called to care for this pt. If you felt that there were things about his/her condition that they didn't understand before going home then I believe that you were obligated to make them aware. If you felt that they were altered and not able to advocate for themselves, you were unquestionably obligated to do so. In this case you knew the pts wishes yet wished to thwart them as they made you uncomfortable, and that is the point that I believe you went off into the ditch. See? Yes, if the pt was mentating appropriately, then following his wishes was the right thing to do. No, it's not. You are not ultimately to do what you're told, you are ultimately to do exactly what you're doing now, which is learn to make the most competent, medically, morally and ethically sound decisions that you know how to the benefit of your pts regardless of your feelings. Will you end up in a shit storm because of it? Likely. When I was fired from my last job one of the last things the manager said is, "You do good medicine, it's just not paramedic medicine. We're not supposed to make people better, we're just supposed to save them if they're dying." I didn't know it then, but getting fired was exactly the right thing for me as I refuse to work in such a way. I, as well as the others in this thread I'm guessing, find the morals and ethics of EMS to be at least as challenging as the medicine. I think that its possible that you read the replies from those that have been doing this longer than you and see that this is a simple decision for them, or me. It's not, it's only that we've had a few more days to think about it. I know how vitally important this topic is to those that have posted answers for you because I can see that their answers were not canned. They have thought about these issues from every angle, over many patients, had a bunch of broken hearts while developing the answers that you've been given. So please don't see them as flippant. I was called to a lady during my FI at a new job a while back. She was in her late 80s, had been released from the hospital a few days before and her L lower leg was hugely swollen. She had been diagnosed with cellulitis which had now caused her entire lower leg to turn bright tomato red, hot as hell as well as cause her to present with general early stage sepsis. She was certainly going to die if she didn't choose to go to the hospital. We were not called by her but by a neighbor I believe... She was mentating clearly, language quick and concise, much more intelligent and well educated than myself and many of my coworkers, and simply didn't want to go to the hospital because she knew that when she showed up that they would see that she was not becoming better, was unable to care for herself, would involve social services and she would be forced into a nursing home, her greatest horror. And she was prepared to die, in fact may have even welcomed it. As a pt advocate, I wanted to refuse her, believe it or not. My instructions had been thorough up to and including, "Do you understand that it is my sincere belief that if you don't come with me today that we will be collecting your dead body from this chair within the next day or two? Not sicker, but dead.?" "If you have anyone that cares for you then you have no right to make such a foolish and selfish decision!" Lady, "I have no one that cares for me, no children, my family is all dead." Etc. Didn't softball her. But, as I was new at this service I chose to involve (after nearly an hour of effort) the police, my supervisors and social services to show them that I am in fact a team player. The police put her on a hold, I think, with social services signing off on it as her guardian, we took her to the hospital where she was treated and transfered to a nursing home who found her dead secondary to suicide a few weeks later. Oprah maybe would praise my efforts, but the bottom line is that this woman knew her own mind, she had a human right to choose to live and/or die at where she chose, yet me and a bunch of other yahoos decided to 'do the right thing' and make her die miserably. Major bruise to my paramedic spirit. You worry that you helped this pt make a decision that would bring them harm, and that is simply not true. You helped, or your partner did at least, this person carry out the decisions that they had made for themselves. Two completely different things. I love the fact that this is giving you heartache. I love the fact that you're pissed off that people don't seem to care about this patient. And I'm confident that if you are strong enough to have convictions and stand by them, a rarity in EMS, that you are going to be a fucking rock star medic. Dwayne I can promise you that it's an even shittier feeling knowing that you've taken someone in the last days of their lives and physically forced them to live out those days in a manner that they despise. It occurs to me that we haven't, in all of this learned conversation, considered the bullshit factor here. The truth is that some pts want to stay in the hospital. They like it, and the care that they receive, there much better than they like home or a nursing facility. But the truth of the matter is that we simply can't afford to keep everyone there that would like to stay. As I reread your post it sounds like it is possible that this pt was giving the answers he believed that he needed to give to be too sick to go home or to a nursing home but yet sick enough to stay in the hospital. I can't think of a single pt that I've had that TRULY wanted to go home that would admit to not being able to care for themselves. It's almost always the opposite. They are swearing that they can (as in the leg lady) when I know damned good and well that they can't. Just a thought... Dwayne

This is a valid question indeed. Here is the tough part. EMS is not required, but rather "hired" as a medical taxi so to speak, for these patients. Your responcibility is to your company, if they tell you to do hospital to home transfers, you do it. However, if the pt is not safe at home for any reason, it is up to you to advocate for them. That is all you can do. We do not know this pts motives.

So, after reading another thread I got to thinking that it would be nice to have a place where we could all share our knowledge and form a compendium of evidence based medicine in relation to the treatments we in EMS and emergency medicine in general provide, have provided, or may provide in the future. I am aware that many if not most of the treatments we give are not supported by scientific evidence, but I realized after reading another thread on here that there are more treatments unsupported by studies than I thought. The rules of the thread are thus: every point is disputable, however all claims must be backed and supported by references to peer-reviewed academic studies. And while the studies may tell us one thing, I also want to know what your personal and individual experiences with these treatments are; because we all know that what we read in a book and what happens in the streets are two very different things. The goal is to find as much credible evidence for or against as many prehospital treatments as possible, and also for in-hospital treatments. Oftentimes, we look at these studies in relation to how we in EMS should be doing things, but what about the hospitals? Are they advising us against the same unfounded treatments they themselves continue to provide and are any of these treatments beneficial for ANYONE in any setting?

I'm not exactly sure what you mean by "teching" the patient. As kinda a just that I have gathered you had a patient that could not fend for themselves and you did not feel right leaving them at home when you know they are going to be alone for the most part with the exception of when the aid is present in the home. Please correct me if I'm getting the wrong impression. If my impression is correct then I have a couple thoughts.1. There is an old addage you can lead a horse to water, but you cannot make him drink. I won't argue that the patient probably should not be left alone at home in his state. However if he refuses provided he can legally make decisions, then you have to respect their wishes. Situations similar to this happen all the time. The ethics debate usually ends with patients rights. To go above the patient, you would need to get something from the court. Otherwise it sucks but your at a loss. 2nd and I know this might sound like kicking a dead horse but provided they can legally make decisions they have a right to dictate their own care. Again sucks to be us sometimes. And third and most important talk to your patient regarding your concerns if you feel comfortable and appropriate. Sometimes a second person stating the same thing as the physician and providing other angles to look at may prove to be beneficial. Just don't get into a arguing match. That will only serve to piss off your patient and get you nowhere.

I've done my best to be polite, respectful and helpful, but I seem to be coming up against a wall here. I would like to think that is true, but a really have my doubts. If you were really interested in obtaining data I would have thought that you might like to know where I source my statements from. I'd be happy to furnish you with references, but it does not appear to be important to you, and while you are happy to agree with me without question when my statements correspond to your desires, you are also happy to dismiss out of hand any contrary position. It seems to me that you are interested in getting more "toys" rather than improving patient care. Improving patient care has little to do with how many drugs you carry, and even less to do with what other services carry, but everything to do with the judicious application of best available evidence by well educated and experienced providers as an integrated part of the health system at large. I hope you come to this realization sooner rather than later.

I am not building a case with protocols. It was a like to know for me; so I can see how systems really differ. I like to find out from others; like if I was at an EMS Convention speaking to you. I just wanted to hear it from people in the same field instead of reading it off the computer. I guess I have to do more that apologize and rephrase. As for google; yes I do. If someone asked if I can give a medication or not; can I treat and how. I would answer it regardless of their intentions. I can google it but what would be the point. Everyone on this forum ask others and they probably can google it. Its a regional question I'm asking, which is unique to that region. So, I quess I don't need to ask since I can google it and this forum is not for asking peers anything. I guess I'm learning new things on this forum. Thank you all. Have safe and wonderful New Year...