Do we diagnose, rule in/out, or just load and go.

[Richard B the EMT]

Ventmedic, we agree, that is exactly why this patient has to go. My state and local protocols require, nay, DEMAND this patient be transported for further evaluation and treatment in the Emergency Department.

[scott33]

If at some point in the future higher-ups decided to allow field decisions to be made regarding denial of transport and/or field treatment alone, that would require a true-blue differential diagnosis. That would require a doctor, not a pre-hospital allied health provider, and thus would spell the end of all of us. So we should be careful what we wish for.

It wouldn't require doctor. Works perfectly well in other systems, and frees up much needed space in EDs. Try Googling - "Emergency Care Practitioner".

[akflightmedic]

Ventmedic, we agree, that is exactly why this patient has to go. My state and local protocols require, nay, DEMAND this patient be transported for further evaluation and treatment in the Emergency Department.

Does this mean the patient can not refuse your "DEMAND"?

[PabloT]

I don't see how a patient can be refused the right of refusal if they are A&OX3. It is their right to allow care or refuse it and they can change their mind at will. I don't want to live in a world where a medical professional has the right to dictate the care I WILL receive even if I say no.

We have a number of items in our protocol that state the patient MUST be transported (like diabetics who receive D50). Nevertheless, it is against the law to not allow them to sign the refusal if that is what they choose to do after being duly warned of what could happen.

[tskstorm]

Ventmedic, we agree, that is exactly why this patient has to go. My state and local protocols require, nay, DEMAND this patient be transported for further evaluation and treatment in the Emergency Department.

You can always call telemetry and push the blame on them

[VentMedic]

I don't see how a patient can be refused the right of refusal if they are A&OX3. It is their right to allow care or refuse it and they can change their mind at will. I don't want to live in a world where a medical professional has the right to dictate the care I WILL receive even if I say no.

Guess what? You do.

A&Ox3 may not be the best indication of competency. Many people in psych facility can answer those 3 questions. This is why we have medical and legal guidelines for people that will do themselves harm by refusing medical care. Even if you answer these questions correctly, a 72 hours hold can be placed on you for "observation" which will confine you to someone's care. This will be in your best interest per some laws. States have a variety of statutes that will confine you for drugs and alcohol against your will "for medical treatment".

There will always be do gooders that will want to force feed you even if you have your DNR papers in order. This can also include your family if they are pressured by the opinions of others.

You will also have medical insurance problems that will dictate which doctor you see, which hospital and what tests you can have. They will also tell you which disease you can or cannot have if you want coverage.

[PabloT]

A psych issue is very different from a standard medical issue. The law states that if I try to kill myself, I can be declared incompetent. A case of an asthma patient...who understands their condition and refuses transport to the ER after an breathing treatment....is a completely different case.

As for the insurance issue, no one is required to do anything they say. The free market is still in place. The insurance company has the right to refuse payment, but the patient can flip the bill if they choose.

Granted......almost no one can afford to do that. However, the patient can then change insurance companies or pay on their own. My point is simply that there is no LEGAL requirement to do what the insurance company tells you to do.

[VentMedic]

A psych issue is very different from a standard medical issue. The law states that if I try to kill myself, I can be declared incompetent. A case of an asthma patient...who understands their condition and refuses transport to the ER after an breathing treatment....is a completely different case.

If you know the patient has an altered mental status for a medical reason, even if they answer your 3 little questions, they can still be held for medical evaluation.

If a patient puts their head through the windshield of a car in an MVC and is wondering around dazed but answering questions, are you going to just let them walk away. Hopefully not.

If a patient is seriously hypoxic to where they are altered, they may still respond to questions, but are in no shape to make a decision for themselves.

Pts with high alcohol or drug levels can also answer questions but should not be signing a legal document saying they are competent.

There are also several electrolytes imbalances that present with slightly altered mental status to where the patient is not displaying enough good judgement to make a competent decision.

These are also reasons why we hope for a rational adult availabe who is also able to assist in making some medical decisions for patients.

Getting a signature on a piece of paper may not relieve you from liability. It may just prove you failed to do a full assessment or talked a patient having an MI into taking an antiacid for that chest discomfort.

No an insurance company can not force you to do anything. You can just go into medical debt and pay for medical treatment yourself which will include the ambulance bill.

[CBEMT]

That's all well and fine, Vent. And none of it is going to make me tell my chain-smoking asthma patient who has no air conditioner for the summertime that because I gave her an albuterol treatment as she requested, she now has to go to the hospital whether she like it or not in spite of her desire to refuse without prompting, adequate mentation, normal vital signs, and no evidence of hypoxia.

[Richard B the EMT]

Akflightmedic wrote

Does this mean the patient can not refuse your "DEMAND"?

And tskstorm wrote

You can always call telemetry and push the blame on them

In response to both of those thoughts, there are local protocols that come into play, and they actually do involve calling OLMC. Usually, after the doctors talk to the patient, the patients decide to go to the hospital, but if they still don't, and I won't spell it out in full here (due to space and time considerations), a LEO/protective custody element is activated.

However, if the patient goes unconscious, even if they used their last moment awake arguing against going, it becomes a non issue, as unconscious patients are presumed to want to go to the hospital, and we oblige them.