Was I Wrong?

[Bieber]

(Disclaimer: some details have been changed to further preserve anonymity.)

So I worked yesterday as an EMT with a partner I had never worked with before. For those of you who don't know, I'm done with paramedic school and my practical boards, and I'm taking the written on the fifth, just as a little FYI. Anyway, our last call yesterday was a transfer of a patient from the ER of a bigger hospital who was going back home. The patient had been brought in by EMS earlier yesterday for bilateral knee pain and stated that they had fallen the day before. The patient usually got around with a walker but said that since the fall they hadn't been able to get around at all and the ER had diagnosed him with just a sprain and had put a splint on his left leg. I was up to tech since it was a code green and while my partner was in the hallway copying down the patient's information I was in the room talking to the patient, and I asked the patient if he was able to walk at all. The patient said no. Then I asked the patient if he was going to be able to get around with his walker even to get to the bathroom or the kitchen--no. The patient also stated he lived alone in an independent living apartment and had a home health aid that came in every day. At that point I went out into the hallway and told my partner that, hey, this person isn't going to be able to get around at home and take care of himself, we can't just leave him there. My partner said something about it being cute that I "cared about the guy" and then said they were going to "throw the patient in their bed and leave". At this point I was very uncomfortable with the whole thing, and my partner asked if I wanted him to tech, and I said yes.

The patient couldn't even slide over from the hospital bed into our cot, we literally had to slide him over, which we did. From there we loaded him up and I drove to his apartment and we got him into his room on the cot. The patient asked us to put him in his bed and we had to actually physically pick him up and put him in it; it wasn't like he used us for support while he stood himself up and turned to sit down--we literally had to do all the work for him. He had a stand next to his chair with a phone on it, and I asked him again if he was even going to be able to go to the bathroom, and he said no. My partner told the patient he was going to be calling us right back, and the patient acknowledged that that was true. Apparently the hospital had tried to convince him to stay and go into a nursing home but he had adamantly refused and repeatedly told us he didn't want to go to a nursing home.

When we left and got back to the station my partner chewed me out about not taking the call and basically said if I pull that shit again that "no paramedic's going to back you up for that" because I ought to be taking all of the code greens as an EMT, and there was talk of an incident report but he said he wasn't going to write one up but he did show me the part-timers' evaluation form that the lieutenants fill out for us at the end of every shift and asked me in a knowing way what I thought I should get for my evaluation that day.

I really, really don't like to leave someone at home who is incapable of getting from point A to point B, and I remember during my internship neither I nor my preceptors would ever let a patient stay at home if they couldn't get around. And I get that the hospital can't make him stay against his will, but why does that mean that WE have to help him to his own demise? The guy could have taken a taxi or found some other way home (actually, he couldn't, since he couldn't get around, which is why WE got called, but still in principle he could have). I kept thinking about what my preceptor told me once after I had particularly screwed up a call during internship and tried to refuse someone I shouldn't have, about how I would NOT leave HIS family like that, and I kept thinking that, if this patient had been my preceptor's father, what he would say to me for leaving him at home helpless.

So my question to you is this: was I wrong to protest teching that call on principle? Should I have just shut up and take him home without raising my voice against it? As far as I know, we have no obligation to provide a taxi service for patients going home from the hospital, only to provide transport and treatment to patients going TO the hospital. And yeah, I know that guy was going to find a way home one way or another, but I strongly feel that we should not be involved in helping someone to harming themselves.

The first and highest edict in medicine is primum non nocere, first do no harm. But I feel like by having had a hand in putting that man in his home and leaving him there helpless, we have caused harm.

[HERBIE1]

I see 2 issues here. First, your refusal to "tech" on the call. That's fine, but what exactly were you trying to accomplish? Either way, you would be present on the call- whether you were driving or teching.

Second, leaving an immobile patient at home with no help. You mentioned that a home health nurse would be coming by, but it sounds like this person needed 24/7 assistance- bed pan, physical therapy, etc. Clearly the person did not want to go to a nursing home for rehab, which is their right- absurd as it may seem to you.

I would notify the hospital's social service department of the situation, but I would hope they have already been made aware of it. Maybe they made plans you were not aware of. Reiterate the situation to them, tell them the person needs help, let them work out insurance issues for any aides, etc, and then I'm afraid there is probably not much more you can do. You could have refused to take the person home- which would probably resulted in the loss of your job.

What did the person say when you asked how they would be able to feed themself, get to the bathroom, bathe, etc? Were they competent? Did they understand they NEEDED the help?

I've had people flat out refuse our care and/or transport- even when we suspected a serious cardiac event was happening. Bad, and probably a bad outcome for them, but some things are also beyond our control. Make as many people aware of the situation as possible, ensure they understand exactly what you mentioned here, and hope for the best.

Lots of gray areas in this business, Bieber and I can promise you one thing- it will happen again.

One last thought- did this person sign out of the hospital AMA- against medical advice, or was it a formal discharge?

Edited January 3, 2011 by HERBIE1

[wrmedic82]

I'm not exactly sure what you mean by "teching" the patient. As kinda a just that I have gathered you had a patient that could not fend for themselves and you did not feel right leaving them at home when you know they are going to be alone for the most part with the exception of when the aid is present in the home. Please correct me if I'm getting the wrong impression.

If my impression is correct then I have a couple thoughts.1. There is an old addage you can lead a horse to water, but you cannot make him drink. I won't argue that the patient probably should not be left alone at home in his state. However if he refuses provided he can legally make decisions, then you have to respect their wishes. Situations similar to this happen all the time. The ethics debate usually ends with patients rights. To go above the patient, you would need to get something from the court. Otherwise it sucks but your at a loss.

2nd and I know this might sound like kicking a dead horse but provided they can legally make decisions they have a right to dictate their own care. Again sucks to be us sometimes.

And third and most important talk to your patient regarding your concerns if you feel comfortable and appropriate. Sometimes a second person stating the same thing as the physician and providing other angles to look at may prove to be beneficial. Just don't get into a arguing match. That will only serve to piss off your patient and get you nowhere.

[Bieber]

I see 2 issues here. First, your refusal to "tech" on the call. That's fine, but what exactly were you trying to accomplish? Either way, you would be present on the call- whether you were driving or teching.

I suppose nothing more than trying to be firm in my principles. I know I didn't accomplish anything, but I didn't want to just cave in on my principles either.

Second, leaving an immobile patient at home with no help. You mentioned that a home health nurse would be coming by, but it sounds like this person needed 24/7 assistance- bed pan, physical therapy, etc. Clearly the person did not want to go to a nursing home for rehab, which is their right- absurd as it may seem to you.

I would notify the hospital's social service department of the situation, but I would hope they have already been made aware of it. Maybe they made plans you were not aware of.

Perhaps they did, though it didn't sound like it.

Reiterate the situation to them, tell them the person needs help, let them work out insurance issues for any aides, etc, and then I'm afraid there is probably not much more you can do. You could have refused to take the person home- which would probably resulted in the loss of your job.

Yeah, I think so too.

What did the person say when you asked how they would be able to feed themself, get to the bathroom, bathe, etc? Were they competent? Did they understand they NEEDED the help?

He said he wouldn't be able to feed himself or go to the bathroom, and yeah, he was competent and understood he needed help. Stubborn.

One last thought- did this person sign out of the hospital AMA- against medical advice, or was it a formal discharge?

I'm not sure. I assume it was a formal discharge since the patient had been cleared medically.

I'm not exactly sure what you mean by "teching" the patient.

Sorry, I meant acting as the tech on the call.

As kinda a just that I have gathered you had a patient that could not fend for themselves and you did not feel right leaving them at home when you know they are going to be alone for the most part with the exception of when the aid is present in the home. Please correct me if I'm getting the wrong impression.

That's all correct.

If my impression is correct then I have a couple thoughts.1. There is an old addage you can lead a horse to water, but you cannot make him drink. I won't argue that the patient probably should not be left alone at home in his state. However if he refuses provided he can legally make decisions, then you have to respect their wishes. Situations similar to this happen all the time. The ethics debate usually ends with patients rights. To go above the patient, you would need to get something from the court. Otherwise it sucks but your at a loss.

2nd and I know this might sound like kicking a dead horse but provided they can legally make decisions they have a right to dictate their own care. Again sucks to be us sometimes.

But are we obligated to help the patient along? I mean, if someone wants to refuse care and go back home that's their right, but do we have a responsibility to ferry them home and leave them there? Is there any legal obligation for EMS providers to provide a ride home for patients leaving the ER? And should we have any hand in it knowing it will be deleterious to a patient?

[Chief1C]

I didn't read the whole thing. The furnace is off in the station, and it's about 42 degrees in here. ... I would have refused to transport the patient. I've done that before. I'm a fireman. Egress. How will that person get out, if their home is on fire. If they can't walk, they have no means to do so with an alternate method; and they have no 'round the clock aid... How will they get out? They won't. That's my argument every time I'm faced with a patient who is either being transported home; or called 9-1-1 and is refusing. I see it as a liability upon the service. It may or may not be, but still, it eats on my conscience.

[HERBIE1]

I didn't read the whole thing. The furnace is off in the station, and it's about 42 degrees in here. ... I would have refused to transport the patient. I've done that before. I'm a fireman. Egress. How will that person get out, if their home is on fire. If they can't walk, they have no means to do so with an alternate method; and they have no 'round the clock aid... How will they get out? They won't. That's my argument every time I'm faced with a patient who is either being transported home; or called 9-1-1 and is refusing. I see it as a liability upon the service. It may or may not be, but still, it eats on my conscience.

Right or wrong, if a person is competent, they can do whatever they want. People choose to do all types of things they shouldn't- drink and drive, ingest drugs, eat unhealthy foods, refuse to be compliant with their medical care and/or medications- and even go home when you know they will have a difficult- if not impossible time caring for themselves. The OP stated there was a telephone nearby, so the person will probably realize at some point they DO need help, if it's not forthcoming via some social service agency, and they will reach out to someone.

It's not our job to ensure that someone makes the right choices. We do the best we can, we educate them, we explain in the most graphic and blunt terms possible- the possible consequences of their actions, and then let them be. Provide alternative solutions if we can, provide them with It's no different than a refusal of service or transport. We may KNOW a person needs medical attention, but sometimes, despite our best intentions, they simply refuse.

I should have also added that another action for the OP should have been to contact the employer for guidance.

I would ask my supervisors exactly what the company policy would be in this situation, and what my- and the company's liability's are in such cases.

[Bieber]

Right or wrong, if a person is competent, they can do whatever they want. People choose to do all types of things they shouldn't- drink and drive, ingest drugs, eat unhealthy foods, refuse to be compliant with their medical care and/or medications- and even go home when you know they will have a difficult- if not impossible time caring for themselves. The OP stated there was a telephone nearby, so the person will probably realize at some point they DO need help, if it's not forthcoming via some social service agency, and they will reach out to someone.

It's not our job to ensure that someone makes the right choices. We do the best we can, we educate them, we explain in the most graphic and blunt terms possible- the possible consequences of their actions, and then let them be. Provide alternative solutions if we can, provide them with It's no different than a refusal of service or transport. We may KNOW a person needs medical attention, but sometimes, despite our best intentions, they simply refuse.

I should have also added that another action for the OP should have been to contact the employer for guidance.

I would ask my supervisors exactly what the company policy would be in this situation, and what my- and the company's liability's are in such cases.

I don't disagree that the patient has the right to do whatever they want, my point of contention is whether or not we should be helping them by providing transport for these people. We may not have the power to stop them, but is it right for us to be complicit in their harmful decisions?

I may try to find out more about my service's policy, however the way things are I'm a bit afraid of possible recourse for probing too deeply into this matter.

[mobey]

I don't disagree that the patient has the right to do whatever they want, my point of contention is whether or not we should be helping them by providing transport for these people.

This is a valid question indeed.

Here is the tough part. EMS is not required, but rather "hired" as a medical taxi so to speak, for these patients. Your responcibility is to your company, if they tell you to do hospital to home transfers, you do it. However, if the pt is not safe at home for any reason, it is up to you to advocate for them. That is all you can do.

We do not know this pts motives.

[Happiness]

So first of all I cant get over "Awe thats cute, you care about this guy"...well i think someones partner has forgotten about why we do this..just saying.

You can't take your principles and expect your pt to have the same one's. It sound like this pt was competent in his thought process. Everyone one has the right to be in their own home and with their own belongings, that is were we feel safest. If you would have refused this call, someone else would have done it. I'm not to sure why you stated your job is to take pts to the hospital, not take them home. They are very low priority calls but I think they happen in every community.

I have had to take pt's home to dirty, moldy and there has been slime involved, Do I have the right to not take them home because I live in a clean and unmoldy house...Nope it is not my place to judge how others live. I dont like doing it, but I do.

If you had made a real big stink it would only have made you look like the trouble maker..there will be other calls in your career that you will be able to make that stink, so I guess Im saying pick your battles. this guy had some sort of home care on a daily basis so he wasnt completely being abandoned.

[island emt]

We'll give you the benefit of the doubt as a newbie in the business Bieber.

As long as you work for a transport company: Yes it is your job to haul people from one place to another.

Did this PT have needs that weren't being met by leaving him alone at home?

More than likely, but did you ask him if there were family members or neighbors that could assist him?

Did you offer to call them for him?

Does the daily home care aide help him with personal care and making meals for him?

Does he have a wheelchair or did you offer to see about getting him one from the hospital?

There are many ways we can advocate for our customers, however we cannot go against their wishes as long as they are capable of making informed consent.

As far as refusing to "tech" the transport call based on your principles, :: You would have been standing on the curb looking for work in most places.

Pick your battles where they will make a real difference , young Jedi!

Edited January 4, 2011 by island emt