Deny Patients a Ride In the Ambulance - What Laws?

[spenac]

Don't get me wrong, I am a huge advocate (as some can tell you) of treat and release programs. I just don't advocate treating and releasing patients who may rapidly decompensate and die within 24 hours of our release. Get my drift? If you can make a field diagnosis, given presentation, that will generally result in the patient both surviving and giving them "reasonable" time to properly advocate for themselves, I'm all for it. What I mean is:

A) Better educated Paramedics who are capable of understanding the true implications of releasing a patient, with a given presentation, to home.

Making sure the patient is reasonably well to come home, mentate, and remain well enough to involve the health care system in any further deterioration. Doctors release patients to their homes all the time without necessarily running a battery of test, but they understand those implications and they definitely release them in a state of being where they're capable of recognizing any increase in illness. All to often we (EMS) leave chest pain patients, unstable diabetics, and demented elderly patients at home without much of a chance.

There is a perceived finality to calling 9-1-1. We are the safety net of health care. If someone calls for us, they generally believe it to be such a severe predicament that they need transportation to a hospital. Granted we all understand there is severe abuse in the system, but I haven't seen a good way of properly filtering these patients out with the current toolset available to EMS providers (mainly education wise).

I see more where you are coming from now. I have a medical director that expects us to be up to date. We do have criteria that would eliminate us not taking a patient that has problems as you describe. There is no 100% way of knowing a person will not die within 24 even with all the resources at the best hospital in the world. So the fact that a person dies 24 hours after being seen would not in it self lead to you losing a lawsuit.

Now I agree education is lacking in many schools and in many services it seems. We really need to start a new topic because we are hijacking my thread. I really want to see any federal or state laws that say you have no choice but to transport all that ask.

[AnthonyM83]

3. I knew of a 911 service that implemented a no transport for DNR patients, which was disasterous. Grandma dying, ambulance comes, refuses to take grandma -- family and nursing homes are upset.

That seems to be asking for problems. Just because someone doesn't want to come back if they die, doesn't mean they want to deteriorate with increased pain and suffering. Even people with terminal illnesses can have unrelated treatable problems.

[crotchitymedic1986]

Umstudent is dead on. No matter how much education or years of experience you have, there is always that handfull of patients each year who didnt get transported on the first request and either they go to the ER on their own and are found to have a serious problem, are transported by another ambulance on second request -- after getting worse, or die at home. And those of you who have worked an ER job, and have had to treat the patients that ambulance crews leave behind know what i am talking about (when you work an ER you usually get to see 5-6 counties of population, whereas if you dont work ER, you may only be familiar with your services mistakes -- since we dont advertise them). You have to have lab and radiology to know for sure. Like I said in another post, the AMR study that found that 2% of all patients not transported (refusal or not needed) are admitted to ICU and 1% die is accurate. You figure out what that means for

your services call volume:

Number Not Transported ICU Admits Deaths

1000 20 10

2500 50 25

5000 100 50

10,000 200 100

But you can still claim that "hey we were right 98% of the time", but that 2% of wrong can cost you alot of money

[spenac]

Crotch the ER has similar numbers of sending patients home that later die or return and end up in IC. Again no matter how many tests you run you really can not be 100% sure any patient will make another 24 hours.

It makes me sad that so many seem to be content being taxi drivers. I am not saying deny every patient, but why in the hell would I drive someone to the hospital for lunch, to get their stubbed toe checked, that sneezed once last week, I could go on and on with a list that after you exam would be clear there is no need for an ambulance and honestly no need for an ER. As long as we keep the you call we hall mentality we are encouraging people to abuse us and the ER's.

Honestly this is less risky than field selective spinal immobilazation that many services are implementing.

[spenac]

Would you transport the guy in the scenario that started the following topic? Keep in mind I even included an ask God card to be 100% sure that it was not a mental or physical problem.

http://www.emtcity.com/phpBB2/viewtopic.ph...18&start=60

[Capman]

The State of Maine does not have a must transport law. However, the hospital based service I work for "encourages" that all patients are transported.

Now keep in mind that when I refer to a patient, I refer to some one with a medical ailment; no matter how minor. I am not refering to the caller who wants a ride to the corner for a pack of Camel's. To tell the truth, I have never been called for anything like that anyway. I have however, been called for medical ailments as minor as sore throats, dry coughs, out of medication, tooth aches and such. The common denominator among most of these "nuisances" is the lack of transportation. The other would obviously be the notion that an ambulance ride is the backstage pass to an ER room. What most are learning though, is that this is not the case.

I have to tell you that the ones that really burn my ass though, are not the ones without transportation, but rather the ones with it. One specific stands out in my mind. A healthy middle aged man who lives at home with mom has a tooth ache. We are dispatched to this home and notice a car warming up in the driveway. As we take the "patient" out of the home to the ambulance, what do you think mom said??? That's right, you guessed it... "I'll follow the ambulance up to the hospital." What do you think the middle aged man with a tooth ache asked in the rig right after asking what we have for pain??? That's right... "I don't have to sit in the waiting room, do I?" So these are the ones that burn my ass.

As I said, the State of Maine has no law that we transport all who call the ambulance; but our service requires that we transport all who have a medical ailment no matter how minor. Just my input since I didn't see a Maine yet.

[Christopher.Collins]

I sent a brief but descriptive letter to Connecticut OEMS inquiring to our local protocols and laws in this regards. If I hear back Ill post it.

I dont know though... I mean wouldnt it be abandonment to just deny care and transport? Even if it isnt an emergency? I was always taught to politley talk a patient out of transport if they truley dont need it... but I was never once in 5 years told we can legally deny transport.

Dont get me wrong spenac, I agree 100% that we should have the power to deny transports (given certain critera are met and propper documentation perhaps). It would be a good step twords slowing down abuse of 9-1-1.

[Christopher.Collins]

If I may throw in a personal experience though (it dosnt involve transporting, but someone related).

About a year and a half ago I started to develop my usual seasonal sinus problems. I start getting sore throats, stuffy noses... etc. Its something Im used to... but this time was different, sore throat lasted for a couple of weeks and was only intensifying along with other symptoms. Im a stubborn son of a b*tch mind you, and Ill only go to a doctor or hospital if I absoloutley need it. I just couldnt justify going over a nasty sore throat. And Im sure that at the time an ambulance wouldnt justify transporting m either. Eventually I started to feel swelling in my throat and started to labor my breathing, and thats when I decided I had to go.

Got to the 24hr clinic and they took me right in instead of treoge. Diagnosed me with epiglotitis, an infection that is common in children but not so common and sometimes potentially fatal in adults. They started me on IV antibiotics and checked on me quite frequently (it was a busy night no less). I was also told that there is a slim, but still a chance no less, they may need to intubate if it got serious. Fortunatley the antibiotics worked.

~~~~~~~~~

Now, take that scenario and tweak it a bit. Someone calls EMS for a sore throat and states they want to go to the hospital. Pt at the time is not presenting with any life threataning symptoms, RR and vitals are normal. EMS talks patient out of going, and says that they should follow up with their physician in the morning if symptomes dont clear up. Later that night EMS is called back to the same location for the same patient, now in respritory arrest. Would EMS be liable?

I dont think they would per say be liable, afterall the patient was AAOx3, presented with no life threataning signs and was stable throughout the on scene time. But could you imagine living with that? And regardless of if they did right or not think of the consiquences... bad public image and who knows how much in cost of attorney and court fees untill whatever law suit / grievance is blown over.

[spenac]

I sent a brief but descriptive letter to Connecticut OEMS inquiring to our local protocols and laws in this regards. If I hear back Ill post it.

I dont know though... I mean wouldnt it be abandonment to just deny care and transport? Even if it isnt an emergency? I was always taught to politley talk a patient out of transport if they truley dont need it... but I was never once in 5 years told we can legally deny transport.

Dont get me wrong spenac, I agree 100% that we should have the power to deny transports (given certain critera are met and propper documentation perhaps). It would be a good step twords slowing down abuse of 9-1-1.

Really hope they send you law. Now in your state if all operate under one protocol that would basically be a state law then.

Really you have not denied care or abandoned. You came over. Did examination. Even possibly treated. But patient is not in a situation that requires ambulance transport. You have done the duty required.

Don't get me wrong again even in my job where we can deny we still transport most. And in an area where its only 5-15 minutes to the hospital the transport paper work + transport time would be quicker than the denial paper work. In the job that we are allowed to deny we are at least 90 miles to nearest hospital.

The point of this topic is many throw out the law says you must transport all callers. Yet so far only local protocol has been shown. So I look forward to seeing if your state has an actual law.

[Christopher.Collins]

I think maybe Im misunderstanding your overall point, but Im not posative :? If so Im sorry.

Anyways, havnt heard back from OEMS yet but I have spoken to many peers. The general concensius thus far is that no you can not deny care... and that even if you talked them into refusing that theres still huge liability.

They all were in agreement that theres plenty of abuse in the 9-1-1 system and in theory it could be usefull practice... but while other states may allow it, Connecticut is just not set for it. This state is pretty big on being by the book.

These were exact words from one medic I talked to:

Define non life threatening? Could that tooth ache be an MI? Could that leg pain be a DVT that could become a floating embolism? Are those vitals compensatory? The sad reality is that the majority of EMS transports are those that don't need to go by ambulance, and there's a fair number that don't really need an emergency room and would be fine to see their doctor in the morning. That's not our call to make though. If they request ambulance transport, they get it. It's frustrating to say the least, but it's part of the job.

Sorry that I dont have any actually written proof that we can not deny transport. I know that these opinions are pretty much just beating a dead horse. But even if we were allowed to do it... it seems that the majority of providers (that I spoke too) here would likeley let the Doc sort out the abusers and fakers.

I even mentioned to them about how many many times Ive been taught to just try and talk the patient into refusing, and they freaked out. Fortunatley, its not a practice Ive used.

Im just hoping that the OEMS Chief dosnt think Im crazy or negligent if he reads my letter :roll: