to transport or not to transport

[FSU-EMT]

I work for a first responder agency. we do not transport, we have our local ems agency transport all patients. Lately I have been making all effort to NOT have to result in a patient being transported unless their life is in danger. For example I wanted on scene for about 30 minutes waiting for a patients family to come get them and transport the patient their self. I think I did the right thing, but by doing that am I cheating the local ems agency out of runs? your thoughts please

[JPINFV]

I think I did the right thing, but by doing that am I cheating the local ems agency out of runs? your thoughts please

Do you have some sort of duty to generate runs for the local EMS service?

[treaux]

Don't generate transports if they are truly unnecessary, but also don't write off patients that look fine just because they look fine. Think of all the medical emergencies that we don't have the ability to confirm or deny with the tools we are given. I'm glad you are encouraging them to go in their own vehicle if their needs don't require an ambulance. This is one of those things though that can really come back and bite you in the worst ways.

Always think of the patient's condition and possible outcomes. Forget thinking of wasting people's time, "cheating the ems system" or money issues. Patient care always comes first.

[HERBIE1]

I work for a first responder agency. we do not transport, we have our local ems agency transport all patients. Lately I have been making all effort to NOT have to result in a patient being transported unless their life is in danger. For example I wanted on scene for about 30 minutes waiting for a patients family to come get them and transport the patient their self. I think I did the right thing, but by doing that am I cheating the local ems agency out of runs? your thoughts please

First, I would not worry about whether or not the local transport agency was getting short changed- it's supposed to be about what's in the patient's best interests. Issues like that are for policy makers to hash out.

I would be very careful about your policy. First, how do your approach these nontransport calls? What do you tell the person? How do you evaluate them- V/S, lung sounds, EKG, pulse ox, glucose, etc? The patient will always ask something along the lines of "Will I be OK to go by car, and not an ambulance?" That's a loaded- and very dangerous question, which requires an honest answer.

Obviously the situation depends on their chief complaint, but often times their stated problem is only the tip of the iceberg, and they have underlying problems that DO require immediate evaluation. We simply do not have the diagnostic tools or training to rule out many problems. Blood work, Xrays, CT's, ultrasound, etc. You may be putting your license-and your employer- on shaky legal ground by encouraging or implying a person does not need an ambulance.

Obviously someone with a hand laceration where bleeding is easily controlled does not need an ambulance. They may need sutures, a tetanus shot, or even an XRAY, but someone with a vague complaint like abdominal pain can be anything from gas to a ruptured appendix.

I do understand your concerns- especially in this economy. Ambulance service is EXPENSIVE, not everyone's insurance will cover it- especially if it is deemed not an emergency, but that is NOT our call. If you are willing to wait with a family for them to arrange a car transport, then clearly this is not an issue of getting back into service quicker and not wait on an ambulance. Anyone who refuses transport needs to be advised fully of potential risks(however remote), as well as the costs. It HAS to be the decision of the patient and/or their family. As long as they are fully informed- and not coerced into making a decision- then you should be OK as long as you accurately document and converse with medical control.

You will never get in trouble for encouraging transport, but you CERTAINLY can if you do not transport someone who turns out to be very sick.

Example: Years ago, I had a patient(round 30 y/o) who's family called because she was complaining of a head ache all day, and was just laying on the couch. The patient had no idea the family called us, wanted nothing to do with us, and was angry at her family for calling us. Her vitals were normal, although she was a bit photophobic, so I said she could have anything from a simple head ache, to a migraine to a CVA. I told her we would take her to the ER- it was literally about 6 blocks away. She refused, said she would call back if needed or have her family take her to the ER. Documented the run, called it in, and never gave it a second thought. A few hours later, we received a call from another crew who was at the local ER. They heard this patient's family in the ER, extremely upset- apparently her head aches got worse, they brought her in via private car, and she promptly had a seizure at the ER and went into a coma. Turns out she had a subarachnoid bleed and died later that night. We covered our arses, but of course the ER's first question was why we did not transport earlier. We arrived later at the hospital with another patient, I explained to the staff what happened, and they understood. Would the patient's outcome have changed if we transported earlier? The doc at the ER said probably not- it may have simply delayed the inevitable.

Point is, sometimes the simplest things can turn BAD, which means encouraging people NOT to use an ambulance can have very serious- and unexpected- consequences.

[P_Instructor]

I would be very careful about your policy...............................

Anyone who refuses transport needs to be advised fully of potential risks(however remote), as well as the costs. It HAS to be the decision of the patient and/or their family. As long as they are fully informed- and not coerced into making a decision- then you should be OK as long as you accurately document and converse with medical control.

I agree with the 'Herbmeister'. Make sure that all your policies are clear and that you understand them fully. The biggest thing is that you do not offer medical advise, but as stated to inform the patient of the potential risks of refusing medical care. Don't you make the decision that an ambulance is not needed, And finally, document everything with signatures. One little piece of jargon I always use with refusals after the patient is informed is that 'patient acknowledges understanding......"

[HERBIE1]

I agree with the 'Herbmeister'. Make sure that all your policies are clear and that you understand them fully. The biggest thing is that you do not offer medical advise, but as stated to inform the patient of the potential risks of refusing medical care. Don't you make the decision that an ambulance is not needed, And finally, document everything with signatures. One little piece of jargon I always use with refusals after the patient is informed is that 'patient acknowledges understanding......"

Well, as I am sure you know, the dirty little secret in the medical/legal world is that even if you do everything by the numbers, it does NOT mean you are insulated from potential litigation. Nothing like a dead or disabled victim to get some judge or jury to award a huge judgment for a plaintiff, or force a settlement- regardless if the accused have followed all the rules. One little errant or ambiguous word in a report, or from a witness is all it takes to put someone through legal hell. A "good" attorney can make even the best intentions of a provider seem suspect, and they can make even the best written report seem like a "Dick and Jane" book. Most of the time, things are pretty cut and dried, but every so often, we get "one of those calls" where good judgment, (along with the usual CYA principles and protocols) is key to covering your arse.

I don't know about you, but I do not make nearly enough money to accept responsibility for going out on a shaky legal limb.

It's been said a million times here- It's much easier to simply transport, then spend the requisite time and energy explaining/justifying why you did not.

[P_Instructor]

................the dirty little secret in the medical/legal world is that even if you do everything by the numbers, it does NOT mean you are insulated from potential litigation...........

...............One little errant or ambiguous word in a report, or from a witness is all it takes to put someone through legal hell..........

I do agree. Reviewer's beware.

[CBEMT]

I work for a first responder agency. we do not transport, we have our local ems agency transport all patients. Lately I have been making all effort to NOT have to result in a patient being transported unless their life is in danger.

One thing you never say is WHY. Why do you feel that these patients should not be transported by EMS? Do you see yourself as some sort of gatekeeper for the EMS service? What do your protocols say about you playing "alternative transport coordinator"? Are these patients not getting an ALS assessment because you're shoving them all into private vehicles? Is pain management being neglected?

Sounds pretty stupid to me, to be quite honest. You're putting yourself, your service, and your municipality at enormous risk for.... what? What's the benefit to the system as a result of your actions, and more importantly, what is the benefit to the patient?

[crotchitymedic1986]

It's none of your business, and you are putting yourself at great risk anytime you disuade someone from transport. You do not have the proper equipment to make a diagnosis on the scene. You should let the patient make that decision with the transport crew. If the transport crew decides to talk them out of transport, then the liability is on them. Pretend you are in front of the judge: Lawyer to patient, why did you call 911 ? I was sick and wanted to be transported to the hospital. Why weren't you ? EMT FSU told me that I did not need to go by ambulance. Lawyer to EMT FSU, "What did you base your decision to cancel the ambulance on ? EMT FSU: she had normal vital signs, and WWE was on TV so I didnt want to wait 30 minutes on the ambulance. Lawyer to EMT FSU, Dr. Megabucks at the local ER says this patient needed a complete laboratory workup, an x-ray, and an MRI; did you perform any of these tests in the field ?

[HERBIE1]

It's none of your business, and you are putting yourself at great risk anytime you disuade someone from transport. You do not have the proper equipment to make a diagnosis on the scene. You should let the patient make that decision with the transport crew. If the transport crew decides to talk them out of transport, then the liability is on them. Pretend you are in front of the judge: Lawyer to patient, why did you call 911 ? I was sick and wanted to be transported to the hospital. Why weren't you ? EMT FSU told me that I did not need to go by ambulance. Lawyer to EMT FSU, "What did you base your decision to cancel the ambulance on ? EMT FSU: she had normal vital signs, and WWE was on TV so I didnt want to wait 30 minutes on the ambulance. Lawyer to EMT FSU, Dr. Megabucks at the local ER says this patient needed a complete laboratory workup, an x-ray, and an MRI; did you perform any of these tests in the field ?

Agreed. Of course not every patient encounter results in a lawsuit, but there is no way in the world to determine which ones will come back to bite you. It's generally the simple, innocuous ones that get a life of their own.

A simple tummy ache, the patient refuses transport, and it turns out to be a dissecting AAA. You just never know, and have neither the training nor the tools to make a differential diagnosis.