Refusals

[fakingpatience]

(reposted from my question on life under the lights blog)

I have a question for you all about refusals. Let me start with a quick background. I am an EMT at a private EMS agency where we do both transfers and 911. I usually am working with a medic partner. I find that often on refusals, such as when we go to a house to help someone off the floor or similar situations, my partner won't fully assess the patient, and does not do any paperwork on them ("Lift assist only, no info, no signature"). These always make me nervous, because what if the patient does have something wrong with them that we missed by not assessing them, or by not documenting the assessment if we did one. Now as the basic on the truck, I am consoling myself by saying that if the shit hits the fan, it will fall onto my coworker, the medic, but I know that might not be true. Oh, and this isn't just one partner, as I have a different person every day, it is in the culture of the company to not do proper refusals.

Any ideas?

[P_Instructor]

It sucks, but you need to document each and every call regardless of patient contact or not. Even the documentation may not keep you out of trouble in some instances. Example:

I was dispatched to a residence for male with chest pains. While responding, our Comm Center advised that patient called 911 now and refuses any help, does not want EMS, fire, or PD. I even documented this 'cancelled call' with all particulars of address, information obtained over the radio, times and location we were at. Approximately 25 minutes later, another crew dispatched to same location for 'unconscious party.' Fire arrived scene a few minutes prior to EMS and radioed that patient 'Code Blue, CPR in progress." Moral - the wife of the patient initially called 911 because patient was complaining of severe chest pains. Patient then himself called 911 to cancel without the wife knowing. Wife was apparently hysterical because it took EMS 30 minutes to respond to her request. Was going to court until my documentation of 'cancelled call' came to light. You never know when something can or may happen, so even the most mundane call should be documented in some fashion whether you like it or not.

Secondly, it is also your responsibility even though you are the basic compared to the medic. You both make up the crew that responded to the patient's requests, and are both equally responsible.

I know there will be others responses to this thread, pro and con. Do what you need to do, even with the aspect it still may go to court.

[HERBIE1]

P instructor is right. Documentation is crucial to CYA. I don't know the particulars of your service, but is your partner solely responsible for completing the run sheet or can you do it? If so, then do it yourself. If your partner needs to do the documentation, then say something like "I know you don't want to or think we need to, but I'm going to do a quick assessment and document what I find". Offer to do everything and maybe you'll guilt them into helping. If not, then do it yourself.

It's a touchy area since our fire companies get called for invalid assists. They show up, put the person back in bed, whatever- and they go home. If the fire crew is a first responder level, the only paperwork they file is a NFIR- which is a general form for any fire call. No further documentation or refusals needed. Now if an ambo is called and finds the same scenario, then our credo is if there is patient contact, then you must do an exam, obtain vitals, document that contact, obtain a signature, and call it in to medical control as a refusal.

Obviously common sense may dictate other actions. Example- the other day we were called at 1AM for someone allegedly unconscious for unknown reasons. We arrived and found a guy who was having trouble working his home BP machine. He said it would not give him a reading. No complaints, he was just taking his vitals before bedtime to document them for his doctor. We checked the machine- it worked fine, it gave a nice normal reading within his normal range, and that was it. He would never admit that he used a BS complaint to get help, but it was obvious that's what happened. Did I document a patient encounter, obtain a signature, do an exam? No, I simply stated the facts on the run sheet. If I get called on the carpet for that, then so be it, but I've been doing this for 30 years and that has yet to happen. (Knock on wood. LOL)

Technically, did I break protocol? Yep, and I would have no real defense of my actions, but then again, if the person actually had a complaint- other than an equipment problem or a bed ridden patient that needed help reaching their box of cookies because their caretaker in another room would not wake up- true story- then I do the whole routine.

[P_Instructor]

P instructor is right.............

What???????????? You're kidding, aren't ya.........

[HERBIE1]

What???????????? You're kidding, aren't ya.........

LMAO

Why are you so surprised?

[Bieber]

If you're unsure if something is being done improperly, I would consult your administration about the matter as they are more versed in your local laws, protocols and procedures than anyone here.

For me, though, where I work, we can document minimally on a no patient or "assist a citizen" with no signatures required. The crucial part is determining whether or not this is a patient. I won't say whether your partner was right or wrong, because I don't know your system and I don't know the full details, but you need to ask yourself: is this a patient? That is, do they have a medical complaint? If they're alert and oriented x3, competent to make their own decisions, and deny having any complaints, then I would call them a "non-patient". There was a really good video I watched during paramedic school by a paramedic turned lawyer about these kinds of things, that is, determining if someone is a patient or not. The gist of it was, if they have no complaints, no visible injuries, and they're competent to make their own decisions, they're not a patient. And perhaps that's what your partner is getting at, but again, I couldn't say. What are the protocols governing no patients in your service? Are you required to do a full assessment on everyone regardless of whether or not they have a complaint or not?

Now, I'm not saying you shouldn't use your head. If someone fell, you need to not only determine if they injured themselves but what caused the fall as well. Were they feeling weak or lightheaded? Have they been sick recently? Did they lose consciousness? Did they help themselves down or did they hit their head/neck/back on anything? You'll never be wrong to err on the side of making someone a patient, but don't forget that not everyone we see is necessarily a patient either. And maybe that's your partner's comfort level and he/she's making decisions from experience.

[Chief1C]

Even if it's just a verbal assessment, if they called 9-1-1, requested EMS personnel to assist them, I do a my normal PCR and ask them to sign a refusal if they're not being transported. It doesn't cost them anything, doesn't cost us anything. If they fell, and cannot get up, they're a victim of a fall. I ask them the same questions as I do someone that called for, and requested an ambulance for..a fall.

[fakingpatience]

For me, though, where I work, we can document minimally on a no patient or "assist a citizen" with no signatures required. The crucial part is determining whether or not this is a patient. I won't say whether your partner was right or wrong, because I don't know your system and I don't know the full details, but you need to ask yourself: is this a patient? That is, do they have a medical complaint? If they're alert and oriented x3, competent to make their own decisions, and deny having any complaints, then I would call them a "non-patient". There was a really good video I watched during paramedic school by a paramedic turned lawyer about these kinds of things, that is, determining if someone is a patient or not. The gist of it was, if they have no complaints, no visible injuries, and they're competent to make their own decisions, they're not a patient. And perhaps that's what your partner is getting at, but again, I couldn't say. What are the protocols governing no patients in your service? Are you required to do a full assessment on everyone regardless of whether or not they have a complaint or not?

We don't have an official publicized policy on refusals like this, we don't have policies for many things. Our QA/QI person is not well respected, and is supposed to be reading all my PCRs since I am new, but has not said one word to me about any of them if they are OK or not...

I think many people do look at many of these refusals as a citizen assist, as you say. But say you are called for someone who fell and needs help back up into bed/ their walker, what determination do you use to determine if it is purely a citizen assist? What if they have dementia or don't speak english and there is no translator available? I have had all these circumstance (this is not coming from only one call), and it seems like a truly gray area.

[P_Instructor]

The crucial part is determining whether or not this is a patient.

You are correct with your thinking, but to really make sure everything is documented, don't just use the 'is this a patient' idea. Document any contact whether patient or not, complaint of not, arrived scene or not. With this understanding, the paperwork stinks, but better than your butt.

We don't have an official publicized policy on refusals like this, we don't have policies for many things. Our QA/QI person is not well respected, and is supposed to be reading all my PCRs since I am new, but has not said one word to me about any of them if they are OK or not...

I think many people do look at many of these refusals as a citizen assist, as you say. But say you are called for someone who fell and needs help back up into bed/ their walker, what determination do you use to determine if it is purely a citizen assist? What if they have dementia or don't speak english and there is no translator available? I have had all these circumstance (this is not coming from only one call), and it seems like a truly gray area.

Get a policy

Get a new QA/QI person

Sounds like you need both.

[HERBIE1]

Even if it's just a verbal assessment, if they called 9-1-1, requested EMS personnel to assist them, I do a my normal PCR and ask them to sign a refusal if they're not being transported. It doesn't cost them anything, doesn't cost us anything. If they fell, and cannot get up, they're a victim of a fall. I ask them the same questions as I do someone that called for, and requested an ambulance for..a fall.

Here's the rub. This is exactly what we are always supposed to do, according to protocols. Call in every patient contact- BLS or ALS. Call in EVERYTHING. Some time ago, there was a huge push from the powers that be for this here, and it lasted a couple days. The hospitals cried uncle- they were simply overwhelmed. There is no dedicated telemetry nurse at any hospital, and so they spent all day answering the radio instead of providing patient care. It literally paralyzed the system. They finally agreed that the protocols would be tweaked and that only ALS contacts, refusals, DOA's, or special cases need telemetry contact. Even so, the system was still overwhelmed, so they then instituted abbreviated reports for routine calls to free up the radio. To this day, it is still sometimes difficult to have anyone answer the radio and we end up having dispatch call ahead to an ER. Not exactly the best or most accurate method, but it beats dropping in to an ER with a critical patient, unannounced.

There is the official way, and then there is reality. I will ALWAYS cover my butt- I am known for my detailed documentation. The bottom line is, that in the end, it's up to US to CYA. As anyone who has dealt with a resident or a new RN on the radio, their authority means nothing if they are giving you incorrect information, or they are unfamiliar with our protocols. If something goes wrong, it's our responsibility to and the care for the patient that matters- regardless of the "authority" of medical control. If you are given an order that you know is wrong, it is your responsibility to KNOW it's wrong- meaning just because someone on the other end of the radio tells you something, you cannot simply obey what they tell you if it's detrimental to your patient, or outside your scope of practice. That's why we have standing medical orders- to be able to operate quasi-independently if necessary, and it's those orders that are our gold standard.

My point is that gray areas exist. Experience, training, and common sense are sometimes our best tools.