to transport or not to transport

[JTpaintball70]

Just a student, but I'll share my humble opinion if that's all right.

When it comes to not transporting patients, I am perfectly fine with not transporting patients if a certain number of conditions are met. Really, I guess I'm more on the more liberal side of the debate, and I really don't think transport is necessary/should be done with every patient. You have to be careful, though, because like everyone on here has said, it's a huge risk you're taking. Every patient that refuses, we get a signature from and I am very meticulous in my documenting that the patient refused transport, and I also document and tell every patient that if anything changes they need to call us right back. But you know what? A recent court case showed that it doesn't matter IF you have a signed refusal from a patient, you can still be sued and still lose the case if they decide to come back after you. That little refusal of treatment/transport doesn't mean squat in a court of law. It won't protect you one bit.

So, in light of that foreboding knowledge, the absolute safest thing to do is to transport all patients. And if you choose not to, you had better be very thorough in your assessment, very thorough in your documentation, and very sure that you can justify yourself in a court of law if they come back after you. On the same hand, someone on here mentioned that we, as providers, shouldn't worry about things like medical necessity and costs. Well, I disagree with you on that. Yeah, patient care should always be our number one priority, and shouldn't ever be compromised for anything, but it was a world full of people each being unconcerned with costs that led to the inflation of health care, and it will take a world of people to bring those costs down. Unfortunately, the notion of defensive medicine makes it very hard for all providers from paramedics to doctors to follow their instinct instead of tacking on a transport or a couple additional tests to cover their asses. And again, I'm not saying that maybe that's not what we should do, only that I don't know of any studies that show an increased benefit to cost--if anyone knows of any, please share.

Here's an example to illustrate what I mean, the way my protocols and the protocols at the hospital are set up, all penetrating trauma above the knees or elbows is automatically a code red trauma, and all code red traumas at the hospital immediately get a head CT, chest x-ray, FAST and stat labs and the whole trauma team gets mobilized and an OR prepped. Now, I've had a patient before who DID have penetrating trauma to the leg above the knee, and we DID run them code red, but they really weren't code red. It was an isolated soft-tissue injury, with no other injuries or complaints, know arterial bleeding, no loss of neurovasculars, and no fracture. Did that patient really need a stat head CT, chest x-ray, FAST and stat labs? In my opinion, no. Unfortunately, for whatever reason, they took the "Per paramedic discretion," clause out of the trauma alert protocol, and it's no longer my decision. Yeah, we could have called for orders to downgrade him, and I can't recall why my preceptors chose not to, but this is just a point I make to illustrate that simply following protocol isn't always in the patient's best interest. Like it or not, SOMEONE has to pay for the care we provide and the care the hospital provides, and while we should never compromise patient care for that, that doesn't mean that every patient needs an ER/trauma room/head CT/etc..

In the end, it all comes down to you and how strongly you feel about not transporting every patient to the ER. Does every patient need to go? No, of course not. Nobody here would argue that. But should every patient be taken all the same? Maybe. We don't have the ability to rule out a lot of things outside of the hospital. We can check a 12-lead, take a blood glucose, do a pulse ox and a thorough assessment. Except in a few small cases, we can't do ABGs, we can't do an ultrasound, we can't do much else. So it's going to have to be a judgement call on your part. I know that I won't transport every patient I have, and that I will seek other appropriate avenues for them, but that's my certification to risk. If you want to risk yours too, that's your call to make, but you will be risking it every time you don't transport a patient. As always, I would warn to err on the side of caution and transport if there is any question at ALL about the patient's condition.

Until EMS decides to actually educate providers, we have no business diagnosing in the field and telling people they don't need to be going to the hospital by ambulance. Simply put, US EMS standards are that backwards.

[zippyRN]

So let me get this straight? You denied someone expeditious transport to an Advanced Medical Facility because you diagnosed it and did not think it was necessary? What are you going to tell the prosecutor when he asks you why?

what benefits would ambulance transport bring the care of the patient ?

if you are looking at isolated trauma which is not overly painful and any bleeding is controlled and you have no concerns about bleeding disorders based on proper history taking what dos the patient get from that ambulance ride other than

1. a wait for transport becasue it's a cat C call

2. a bill if you are somewhere that bills

' medical' calls withthe exception of 2 scenarios - transport should be the default ( the exceptions are Hypoglcaemic episodess or seizures in known diabetics/ epileptics that have full recovery and no unusual features and there's a responsible person on scen to keep an eye on the patient)

[Bieber]

Until EMS decides to actually educate providers, we have no business diagnosing in the field and telling people they don't need to be going to the hospital by ambulance. Simply put, US EMS standards are that backwards.

I don't think it's quite that straightforward. And I'm sure if you work in the field you'll agree with me on that. The fact of the matter is that we do diagnose, however you want to spin the terminology, and our diagnoses guide our treatment and even our recommendations to the patients. Do you have a problem telling a patient with a small cut on their finger that they don't need to go to the hospital? I feel that it is our job as medical professionals to be educators as well as providers, more than ever when it comes to pediatric patients and their parents. Because I don't know about you, but I have refused several parents who called for their kids and I have had no qualms doing so. Parents freak out, and that's understandable, but I think that we have to be educators and patient advocates and explain to parents (and all patients for that matter) that first off, we're not doctors, but this is what we're finding, this is what would concern us, and give them their options. They can choose to follow up with their doctor, they can choose to go into the hospital themselves, and they can choose to come with us. But, and this is especially for those pediatric patients, I am going to be upfront and tell them if the patient is stable and I have no suspicion of acute or potentially life-threatening illness or injury, that if they want to go with us we're more than happy to, but you're basically going to be paying for an expensive taxi ride unless something drastically changes. And also, if they choose to stay home, here's what they can do to try to relieve your symptoms.

[Kiwiology]

Our Ambulance Officers have been leaving people at home for thirty years

Get with the program

[uglyEMT]

The more I read this thread the more worried I get I dont know about everyones training or schooling what-have-you but I know that when I was in school I was told we DO NOT diagnose patiens, we are providers, not doctors.

Ok that stubbed toe doesnt need m transport. I get that. BUT I am not refusing a pediatric patient, EVER. I have seen peds go from fine to pucker factor faster then you can read this. Most cardiac peds are from respitory problems. Choking is a big thing, they love putting stuff in heir mouth. Ever seen an exray after a relieved choking episode? Not pretty.

As far as adult patients. If they called its THEIR emergency. Unless its tottaly benign, IE stubbed toe paper cut ect, I will be transporting. I am not loosing my liscence because I felt their wasnt a problem. I do not diagnose, I treat. Once I am trained and educated for a number of years in med school plus internship then certified as a Doctor and add PhD after my name I will be an EMT, Emergency Medical Technian, be it basic intermidiate or paramedic. I am not a doctor thus I treat not diagnose.

I think some are getting that big head and think they can diagnose. I hope ou dont, I dont want to hear of any of us in the City lossing their liscense. I see it in the field alot, folks making desicions based on "diagnosis" versus training and SOP.

Sorry for the rant and I hope I didnt offend anyone but I had to voice my opinion.

Regards,

UGLyEMT

[Bieber]

The more I read this thread the more worried I get I dont know about everyones training or schooling what-have-you but I know that when I was in school I was told we DO NOT diagnose patiens, we are providers, not doctors.

My dictionary defines diagnosis as "The act or process of identifying or determining the nature and cause of a disease or injury through evaluation of patient history, examination, and review of laboratory data." Like I said, you can call it whatever you like, and I'm not saying that we can accurately diagnose every disease in the field (because we obviously can't), but what we do fits the definition of a diagnosis.

Ok that stubbed toe doesnt need m transport. I get that. BUT I am not refusing a pediatric patient, EVER. I have seen peds go from fine to pucker factor faster then you can read this. Most cardiac peds are from respitory problems. Choking is a big thing, they love putting stuff in heir mouth. Ever seen an exray after a relieved choking episode? Not pretty.

As far as adult patients. If they called its THEIR emergency. Unless its tottaly benign, IE stubbed toe paper cut ect, I will be transporting. I am not loosing my liscence because I felt their wasnt a problem. I do not diagnose, I treat. Once I am trained and educated for a number of years in med school plus internship then certified as a Doctor and add PhD after my name I will be an EMT, Emergency Medical Technian, be it basic intermidiate or paramedic. I am not a doctor thus I treat not diagnose.

I respect you and your method of doing things, and if your way of doing things is to not refuse any pediatric patient or most adult patients, then I respect that too. Like I said previously, people have their own ways of doing things and honestly I completely agree that the safest thing is to NOT refuse any patients. However, I do refuse patients, adult and pediatric alike, and I am likely to continue to do so; that's how I've been instructed, and that's my comfort zone.

I think some are getting that big head and think they can diagnose. I hope ou dont, I dont want to hear of any of us in the City lossing their liscense. I see it in the field alot, folks making desicions based on "diagnosis" versus training and SOP.

Sorry for the rant and I hope I didnt offend anyone but I had to voice my opinion.

Not at all. You're entitled to your opinion. And you can think I've got a big head and I'm full of it, and that's all right with me too. And you can call what you do whatever you like, but what I do falls under the definition of diagnosis and that's what I'm going to call it. Can I diagnose everything? No, not at all. Not with my limited resources, and I'm not arrogant enough to think that even if I did have all of the resources that I currently (or will ever, for that matter) have the knowledge to diagnose everything. That's just unrealistic. I make decisions based on my diagnoses and I live with them, for good or for bad. I will always err on the side of transport, but I will also refuse patients that I consider to be in no immediate danger and have no suspicion of going south and who don't want to go to the hospital. And one day that may come back to bite me on the ass. I hope not, and that's why I do my best to expand my knowledge, to better my ability, and to try and make the right decisions. I fully understand the risks I'm taking, and I'm not afraid to come right out and admit it to you guys. And yeah, I'm green as hell, but I'm also following the guidance and leadership of my preceptor, who I consider to be an excellent paramedic, and maybe I'm arrogant to think that because he does it I can too, but I'm at that point in my internship where I'm the one making the decisions, and he hasn't stopped me from refusing anyone yet, so I can only take that to mean that he trusts my judgement enough to trust me to make the right call for my patients. As I grow in EMS and learn more, maybe my opinions will change; but they are what they are right now.

[uglyEMT]

Bierber I hope I did not offend you. I appreciate your comments and your ability. I was talking in general and was not meaning anything twords anyone in particular.

I agree that we all make descisions base don our own knowledge and thats exactly what we all should be doing. I guess my rant was more for the folks that think they are or can be the end all be all of emergency medicine.

Agan sorry if my little rant before offended anyone. I did not mean to come off that way, I just wanted to shake the box a little and have folks think about things a little.

[Just Plain Ruff]

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

all I can say is HOLY CHIT BATMAN!!!!!!! Am I the only one who is shocked at this?

there is a good possiblity if the local ems agency hears of your self imposed policy that they might try to get your first responder agency certification removed.

I know that you think you are doing the right thing and I am sure your heart is in the right place but.......

you are saying that you purposely try not to have local ems transport the patient?

What diagnostic tests do you have to make that determination that a patient can wait for the family to get there 30 minutes later?

Do you have the education to make that decision? As a first responder certification or basic EMT I say you do not have the education to make that decision. DO NOT think I'm calling you stupid cause I'm not, Im saying that you more than likely do not have the education base to determine if a patient does not need to go to the ER by ambulance.

There are some cases where no transport is obvious like ear aches or sprained ankles but most everything else is not obvious.

In my area or neck of the woods the first responders are just that - first responders who have nothing more than blood pressure cuffs, stethoscopes, and Oxygen. Maybe the occasional blood glucose monitor but nothing more.

You are advocating that you are taking this tremendous legal risk of not transporting someone based on what you have found.

Many have said it here before but what legal defense can you offer a judge and jury if the patient indeed needed to go by ambulance but you decided that they could wait.

Guys, this is just the mindset that is killing our reputations and keeping us from moving on to professional status. FSU I'm not focusing on you totally here. We have this attitude and other attitudes that say that I'm an EMT or a MEdic or a First Responder and this guy is not sick so I'm going to advocate that he go to the hospital by another means.

FSU your thought process on this is totally wrong and this WILL come back and bite you in the ass one of these days.

I know I ask patients why they didn't go by ambulance when the ambulance was called and if a patient told me that a first responder said I didn't need to go by ambulance then I'm going to be making some phone calls.

Let's take the case of the medic who saw the high school football player and diagnosed him with dehydration and left the scene. When the parents got home they found their boy dead on the floor. That medic is getting sued and he's going to LOSE and lose BIG time.

When you deny transport or try to move the patient in the direction of no transport then you get on a slippery slope. Your agency does not have any type of no transport arrangement does it? I'll bet there is nothing in your SOP's that allow you to push a patient to not go by ambulance. If you do not have that to back you up then you are in grave risk doing what you are doing. I'll bet your medical director would have a hissy fit if he read your post and remove you from your duties. I know I would.

The legal liability of doing this as a first responder is too huge to ignore.

Keep at your current status quo at your legal and financial risk. Your agency is not going to back you on this I guarantee it.

[HellsBells]

' medical' calls withthe exception of 2 scenarios - transport should be the default ( the exceptions are Hypoglcaemic episodess or seizures in known diabetics/ epileptics that have full recovery and no unusual features and there's a responsible person on scen to keep an eye on the patient)

Why are these the only 2 medical calls that can be canceled on? For intance, we have a protocol where we can cancel on Pts with preexisting SVT that converts with one dose of adenosine.

This issue of refusing transport is of course very divisive issue, particularly with the various levels of education that EMS practitioners have. In the major metro centre in Alberta where I work primary care physicians are becoming very hard to come by, and many people call 911 for problems that are not strictly emergent in nature and may not require a visit to the hospital. We in effect become the first point of contact for many people and have, in effect replaced doctors that used to do house calls in a bygone era. As has been stated before, we are woefully underequiped to act in the capacity of primary care physicians. That said, we cannot continue to take every pt who calls to an emergency dept just because they think its an emergency. There is chronic overcrowding in hospital waiting rooms and we have to come to terms with this.

I think that the prehospital situation is somewhat different in Canada than the USA for a number of reasons. For one we don`t seem to have the fear of litigation that is a common theme through this thread, I honestly can think of very few instances where legal action has been taken against EMS for non-transport. That said, I have no statistics to back up that claim, its simply my opinion. Secondly, we have a more uniform standard of training across the country, particularly now in Alberta, where there are a new set of provinical-wide protocols coming into effect, giving us a clearly defined standard of practice.

Personally, I think that a shift is needed in the curiculum in paramedic education towards community health care. The you call, we haul mentality is outdated. There are other options to hospital tranport, such as transporting to 24hr medical clinics, referring pts who are prone to falls to transitional social agencies, transporting homeless pts to shelters, etc. Now of course, not tranporting to the hospital opens us to libability and risk, but I think that in conjunction with proper medical oversight we can be better advocates for our pts that don`t actually require transport to an ER.

[CBEMT]

Our Ambulance Officers have been leaving people at home for thirty years

Get with the program

And it as easy to sue anybody and everybody for anything- or nothing- in Kiwiland as it is in the States?

Otherwise, you know nothing about it.