to transport or not to transport

[Trip - RKNY36]

There's also the aspect of did the patient want to be transported by EMS? If the pt wanted to be transported by his/her family, the most we can do is convey our concerns and possible outcomes then ultimately respect their wishes, regardless of PHx, CC and such. I guess, in my case, it would be determined on a case by case basis and, if I felt strongly enough, would get Law Enforcement involved. Otherwise...........

[FSU-EMT]

I guess the best thing to do is worry about the patient and nothing else, and do everything to cover my partners ass and mine

[HERBIE1]

There's also the aspect of did the patient want to be transported by EMS? If the pt wanted to be transported by his/her family, the most we can do is convey our concerns and possible outcomes then ultimately respect their wishes, regardless of PHx, CC and such. I guess, in my case, it would be determined on a case by case basis and, if I felt strongly enough, would get Law Enforcement involved. Otherwise...........

Well, the OP said that he tried to dissuade folks from being transported by EMS. That's the wrong attitude to have, and goes against what we are supposed to be all about. There is also a huge difference between actively trying to change someone's mind, and laying out their options if they are on the fence about what they want to do. As you note- ultimately it is the patient's decision, and as long as they meet the criteria for an informed and competent refusal of transport, we must honor their decision, but certainly not try to make it for them.

[kohlerrf]

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?

[Riblett]

There truly are too many unnecessary ambulance transports nowadays. And yes, ambulance service is expensive. Heck, I just now finished paying for my own code three ride to West Boca Medical Center from two months ago. Next time I'll ask will they give me a discount if I do my own 12-lead and IV.

Joking aside, medical necessity and costs are not our concerns as providers. Unless there is truly a concern with unit availability, it should be 'you call we haul'. Even then it is an issue for the higher ups to deal with. It simply isn't worth risking your livelihood, and you don't sound like you even have a solid protocol to CYA. Personally I want to just transport anybody over 65 or under 5, no matter what the complaint is. Obviously they thought it was enough of an issue to call you. Particularly as an EMT you don't have the ability to perform even a decent differential diagnosis in the field. Those suspected kidney stones could be dissecting aortic aneurysm. That granny with low back pain could be having a big fat MI. I'll spare you the hundreds of what if's, but you get the idea.

Edited October 14, 2010 by Riblett

[Bieber]

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.

[HERBIE1]

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.

Here's the deal. Much of what you say is pretty accurate. The problem is,in many cases, we are not in a position to make a decision as to the need for transport to an ER. Yes, I am reasonably certain that we would be safe not transporting something like a finger laceration. But, with all the possible permutations of medical issues- one symptom masquerading or hiding another illness, a yet undiagnosed/hidden medical condition, or a patient who has a complicated medical history, you are taking an awfully big chance by downplaying the need for a transport and ER evaluation. Yes, we get medical control to document our encounters, but that documentation is only as good as the report the provider relates to the telemetry person. Maybe it's a new/subpar/lazy EMS worker who does not accurately relate all the details. Maybe the provider did not do a thorough enough exam. Maybe the provider missed a key piece of the puzzle in his/her exam. That puts the provider, company, department, medical control, and obviously the patient in the line of fire.

Even a subpar doctor has a multitude of tests, exams, and procedures available to them in order to come up with a differential diagnosis. We have no such luxury.

Does the system need to change? Obviously, but we need to be very careful about how we proceed, and certainly we cannot unilaterally begin to change that system. Yes, far too many people are transported to, and seen in ER's that are NOT emergencies. I also see no quick fix- too many political, legal, and philosophical barriers to overcome.

We also need to separate out from this discussion a patient's refusal, vs a provider telling someone there is no medical need for them to be transport. BIG difference. Most systems operate under the assumption(legal based) that an emergency is defined by the person who is calling for help. As such, it would be difficult to stand up in court and say- sorry, but I did not feel that person was in any medical danger. Good luck defending that decision.

Yes, insurance companies also define an emergency- at least in terms of whether or not they will pay for an ambulance or ER visit. That's a different story, and an issue between you and the insurance provider's specific policy. So we have an "emergency" or medical necessity defined quite differently, depending on your point of view. Bottom line- this is a complicated issue, and few of us have the financial and legal resources to defend a borderline decision, should the need arise.

Yes, we DO make judgment calls, but I am far more comfortable with my judgment after 30+ years in the business, vs when I was brand new. Regardless of my experience, there are still situations that give me a significant "pucker factor"- even though I am doing everything by the book. I've simply seen too many incidents where bad things can happen, and some of them far beyond the control of the provider.

[spenac]

There is no reason an ambulance system can not establish a denial protocol. There is no state law that requires transport of all callers. Yes you may have a protocol that does not allow but no one has ever produced a state law saying we must transport all callers though I have asked multiple times.

There would have to be many checks and balances to be successful including making it harder than transporting that way the lazy medic would choose transport over not transport.

[Don1977]

Note to self: Don't get critically sick or injured in FSU EMT's district....I might be better off just walking to the hospital then have you respond....

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 ?

Your dead on.......agree 1000%

[Lone Star]

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

As an EMT yourself, how do you justify talking the patient into transport by POV over an ambulance?

What criteria does a patient have to meet before you'll 'allow' them to go to the E.R. by ambulance?

Since EMT's aren't able to diagnose in the field, how are you able to make this determination with any certainty?

In today’s litigious society, you’re not only opening yourself and your partner up for legal action, you’re also placing your department/company in a very precarious position.

If the patient has called for an ambulance, you are in NO position to try to ‘talk them out of transport’ by the ambulance they’ve called!

If you respond to a scene and an ambulance has been dispatched, you’re in NO position to try to ‘talk the patient out of transport’!

Yes, we all get the ‘bullshit calls’ where we’d rather not transport, but we do it anyway simply because it’s in the patients best interest. What I’m getting from the original post is that there’s some ‘bad blood’ between your department and the local EMS company. How close am I?

If this is how you approach patient care; might I suggest that you either go back to school and relearn the ‘basics’ or just simply turn in your EMT license?

Rather than fretting about ‘cheating the local EMS agency out of runs’, you should be praying to whatever deity you believe in that you and your department don’t end up in the courtroom facing a huge civil suit!