Deny Patients a Ride In the Ambulance - What Laws?

[crotchitymedic1986]

i hear you, but please humor me -- give me your top 5 you would no longer transport under any circumstance

[spenac]

i hear you, but please humor me -- give me your top 5 you would no longer transport under any circumstance

That would be impossible. Every patient would have to examined. They would have to meet a set of criteria. Guy calls 911 wants a ride to lunch. You would have to check him out physically and mentally before saying no. The person with a broken arm, what type of break, good circulation, is pain severe, etc. OB active labor transport them all because they change to darn fast. Guy coughing, skin color, O2 sats, lung sounds, edema.

This is not about shirking the job this is about doing the job right and the job is not taxi driver. You can not say any one illness/injury will not be transported, it would be patient by patient basis. Meet the criteria for saying no say no. If you have any doubts despite the checklist saying you can say no you transport any way.

[crotchitymedic1986]

well said, and well thought out -- good job. But what happens at 3am when you have that lazy medic who would rather be back in his bed ?

[UMSTUDENT]

Not transporting a person isn't so much an issue of administrative law (Code of Regulations, etc), but one of case law (civil proceedings/lawsuits that resulted in judgements that set legal precedent). This is another reason why ALL paramedics need to have a basic college education.

The way the legal system works is pretty clear. All judges rule based on legal precedent ( Stare decisis ), this is especially true when a ruling has been made by a higher court (in progressive appeals) or in a court of equal stature. A lower court's decision may be taken under consideration.

For instance, say that in your state a judge has previously ruled that if you deny transport, and a patient dies, then you are civilly liable for certain damages. THEN if other similar cases are ever brought before that court, or a higher court, you also may be found liable. This is how the English system of law works. This system is true in every State except for Louisiana, which uses a French Civil Law system (laws are interpreted more literally, as a matter of legislation on a case by case basis).

SO, in the United States just because there isn't a specific statute (statutory or administrative law) doesn't mean it isn't so. All it takes is for one judge to interpret an existing statutory or administrative law a certain way to essentially rewrite the way a law is interpreted and applied. Most EMS agencies choose to transport ALL patients who request it simply because they are scared of litigation. Even in cases of lacuna (non liquet-meaning "it is not clear"), or there is no current precedent, there may be one in a neighboring state or elsewhere in the country that makes it all the more likely for a judge to rule a particular way.

When you ask yourself whether it is a good idea to deny transport, seriously consider this: "Is there the possibility of being sued?" This is why it is important to have a politically powerful EMS regulatory authority that has the ability to establish administrative laws. For instance, if you want to give paramedics the unequivocal authority to deny transport then you must establish it via law. Still, of the examples given on this forum, almost all of them include the caveat that there be no "true emergency." Again all it takes is for a judge, with the help of an expert witness, to determine that you used poor judgement.

[spenac]

UMSTUDENT as long as you do your job right and document your findings it would be hard to lose a lawsuit as you describe. they have to prove you were negligent, that you caused harm. I work in one system where we treat and then deny transport. We administer meds such as nubain, promethazine, etc, then let them go on their own. If you live in fear of being sued you really need out of this profession. If you do your job right including denying patients when you can document that there was no need for an ambulance transport you will be just fine.

We are not taxis and if we do not all start pushing for protocol changes though thats all we will be.

[UMSTUDENT]

UMSTUDENT as long as you do your job right and document your findings it would be hard to lose a lawsuit as you describe. they have to prove you were negligent, that you caused harm. I work in one system where we treat and then deny transport. We administer meds such as nubain, promethazine, etc, then let them go on their own. If you live in fear of being sued you really need out of this profession. If you do your job right including denying patients when you can document that there was no need for an ambulance transport you will be just fine.

We are not taxis and if we do not all start pushing for protocol changes though thats all we will be.

If the patient dies, especially within 24 hours of being seen by EMS, you are probably going to loose that lawsuit. Negligence and gross negligence, what I believe you describe above as "harm, are two entirely different things. Gross negligence is generally a total failure,or "blatant violation," of a legal duty (as defined by law).

Negligence is generally defined as "what," if anything, a "reasonable person" with similar capabilities, understandings, and insight would have done given a similar situation. Specifically, negligence can be defined into two very important aspects when it comes to EMS:

Duty of Care and Breach of Duty. If a judge can show that you should have seen "reasonably foreseeable harm" or that you failed to provide a service that would have resulted in less harm, then you're are most definitely negligent. You, as an EMS provider, do not possess the entire gambit of capabilities that a hospital does nor do you hold a professional doctorate stating that you are a "practitioner" of medicine. You are not legally able to definitively tell someone that A) There is nothing wrong with them and They will not die.

Now, your example in regards to treating and releasing is an entirely different arena, but still very shady.

[fireflymedic]

I know cincinatti tried a brief trial of this thought of selective transport refusal based on pre established criteria. Great idea in theory, would have worked well until some monkey medics made the mistake of not transporting appropriate patients 'cause they didnt feel like it ruining the concept. I know a few other areas have given this a try or allowed transport to alternative clinics such as walk ins etc which I think could be a great resource if used appropriately. Would significantly cut down on ER visits and if we could selectively transport, fantastic, but as I said before, uneducated or lazy medics abuse it and you have deadly results. All well, guess we are stuck with what we have for now.

[spenac]

Now, your example in regards to treating and releasing is an entirely different arena, but still very shady.

I disagree with you about negligence. A service medical director establishes reasonable criteria for denying transport. As long as you work within that criteria you have nothing to fear. Again if you live in fear of being sued get out because you will do more harm by omission than by being aggressive. You can not be aggressive if you live in fear of being sued.

Now why is it shady to provide appropriate medical care for an injury or illness and send them on their way rather than costing patient money that could be better used elsewhere and also taking an ambulance out of service when it should be available for a real emergency?

Again we are not taxis, we are mobile emergency rooms. Be a medical professional or get out.

I am so grateful I have such a forward thinking medical director at my now part time job. Wish I could get my current full time job medical director to allow us to get more aggressive in treating.

[UMSTUDENT]

I know cincinatti tried a brief trial of this thought of selective transport refusal based on pre established criteria. Great idea in theory, would have worked well until some monkey medics made the mistake of not transporting appropriate patients 'cause they didnt feel like it ruining the concept. I know a few other areas have given this a try or allowed transport to alternative clinics such as walk ins etc which I think could be a great resource if used appropriately. Would significantly cut down on ER visits and if we could selectively transport, fantastic, but as I said before, uneducated or lazy medics abuse it and you have deadly results. All well, guess we are stuck with what we have for now.

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 too often we (EMS) leave chest pain patients, unstable diabetics, and demented elderly patients at home without much of a chance. I

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).

[UMSTUDENT]

I disagree with you about negligence. A service medical director establishes reasonable criteria for denying transport. As long as you work within that criteria you have nothing to fear. Again if you live in fear of being sued get out because you will do more harm by omission than by being aggressive. You can not be aggressive if you live in fear of being sued.

Now why is it shady to provide appropriate medical care for an injury or illness and send them on their way rather than costing patient money that could be better used elsewhere and also taking an ambulance out of service when it should be available for a real emergency?

Again we are not taxis, we are mobile emergency rooms. Be a medical professional or get out.

I am so grateful I have such a forward thinking medical director at my now part time job. Wish I could get my current full time job medical director to allow us to get more aggressive in treating.

Your medical director has nothing to do with establishing case law*, nor will he get the final say in saying if the care you provided was reasonable. Most likely the plaintiff's lawyer will hire a battery of experts who are more than capable of assisting the lawyer in asking the following questions:

"Mr. Paramedic, did the patient want transported to the hospital?"

"Mr. Paramedic, did you deny the patient transport, against her wishes?"

Mr. Paramedic, is there a giant CAT SCAN machine in the back of your ambulance?"

"Mr. Paramedic, do you have the capability of rapidly assaying a series of basic blood chemistries?"

Again, I'm talking about a wrongful death case here. If your patient dies 24 hours after you last saw them, and the reason is determined to be of an acute cause, you're probably done. I mean, you're talking about administering a narcotic analgesic and a antiemetic. I mean, as an EMS provider you're essentially treating symptoms. I understand that there are tons of patients who have chronic problems that can be mitigated with these medications, but aside from that, it is hard for the current model paramedic to really make a more informed decision.

*Note: If your medical director specifies exact instances where you may treat, release, or deny transport without there being significant medical decision making on your part, you're probably ok. Hopefully he'll hold any liability that may arise.