ambulance or company vehicle

[PCP]

So, I had a worker today come to into my first aid office with head trauma from a fall. I treated the worker for his injuries to his head. The worker complained of a stiff neck, which is to be expected after being thrown off a snowmobile and falling down an embankment about 20 to 30 meters. The patient refused a hard collar and did want to be taken to the hospital by our onsite ambulance, but wanted a coworker to drive him to the hospital.

I told the injured worker and the other workers that came over to check on their fellow worker that I did not agree with him being taken to the hospital in a work vehicle due to the lacerations on his head and tightness in his chest. The worker still refused and managment backed him up on it.

My question is, how far does one go to try to talk the patient into being transported to the hospital by our onsite ambulance, rather than a personal vehicle? The hospital is an hour away from the work site.

I feel that the patient should have been transported by our ambulance where I could have monitored his vitals, gave him O2, been able to give the worker Entonox if wanted, as well as monitor the tightness in his chest, along with the injuries he sustained on his head.

I just don't understand sometimes!!!

[Chief1C]

You must have a pretty well equipped private ambulance. When I think of an in-plant, industrial or remote ambulance around here, you get like an old plumber's van with a first aid bag and a pole stretcher...maybe an ancient rescue basket. Don't know your policies. If I'm injured working, assuming I report it, policy is I have to get treatment, using the most appropriate means. If I don't, their insurance won't pay for it.

[PCP]

I am very lucky where I work, we have a fully equiped ambulance on site. Same as what you would find in any ambulance service. I have access to everything I would normally have while working for the BC Ambulance service, plus a few extras like wooden splints and a few other wound care supplies. It is just hard for me to allow a coworker to transport a patient of mine who I feel needs to be monitored while being transported, not to mention higher care for the patient.

[Bieber]

So, I had a worker today come to into my first aid office with head trauma from a fall. I treated the worker for his injuries to his head. The worker complained of a stiff neck, which is to be expected after being thrown off a snowmobile and falling down an embankment about 20 to 30 meters. The patient refused a hard collar and did want to be taken to the hospital by our onsite ambulance, but wanted a coworker to drive him to the hospital.

I told the injured worker and the other workers that came over to check on their fellow worker that I did not agree with him being taken to the hospital in a work vehicle due to the lacerations on his head and tightness in his chest. The worker still refused and managment backed him up on it.

My question is, how far does one go to try to talk the patient into being transported to the hospital by our onsite ambulance, rather than a personal vehicle? The hospital is an hour away from the work site.

I feel that the patient should have been transported by our ambulance where I could have monitored his vitals, gave him O2, been able to give the worker Entonox if wanted, as well as monitor the tightness in his chest, along with the injuries he sustained on his head.

I just don't understand sometimes!!!

"Sir, do you understand that you could have injuries to your spine or other internal injuries that we cannot find on physical examination and that that tightness in your chest could be due to a heart attack and that refusing treatment and transport via ambulance where we could monitor you and provide treatment en route could result in permanent disability and death?"

Honestly, there's not much else you can do. I've been there, it sucks, but the guy has a right to make stupid decisions. You can ask him over and over and lay the consequences out out cold and honest, but in the end you can't make him go. There seems to be an art to getting people to accept transport that I haven't yet figured out, but maybe some of the more experienced people could give you (and me) some pointers.

[tcripp]

My question is, how far does one go to try to talk the patient into being transported to the hospital by our onsite ambulance, rather than a personal vehicle? The hospital is an hour away from the work site.

I feel that the patient should have been transported by our ambulance where I could have monitored his vitals, gave him O2, been able to give the worker Entonox if wanted, as well as monitor the tightness in his chest, along with the injuries he sustained on his head.

I agree with Bieber's comment on the complexity of the warning statement.

When you get to the point of having to say, "Sir, you do understand that you could possibly die from this?" and they still insist on an alternate means of transportation, just ensure you have a third party - non EMS - witness and ask him to sign here. There's not much more that you can do.

[PCP]

I explained to him that there may be underlying injuries that I can't see or may develop while being driven to the hospital that could not be treated due to being driven by a coworker in a personal vehicle, but that did not work. It is hard to talk a patient to go to the hospital in the ambulance when the patient is the acting mine manager this week. I was hoping one of the other staff members might have spoken up and helped me talk him into being taken in by ambulance, but that did not happen.

I guess I could have kept trying, but I felt he needed to be seen by a dr. sooner than later. All and all it turned out okay, from what I was told. Only a few stiches in both wounds and no damage to the spine.

Main thing is the guy is okay and was able to go home without any major complications.

I agree with Bieber's comment on the complexity of the warning statement.

When you get to the point of having to say, "Sir, you do understand that you could possibly die from this?" and they still insist on an alternate means of transportation, just ensure you have a third party - non EMS - witness and ask him to sign here. There's not much more that you can do.

I did have a third party sign my form as a witness. The same as I do when I am working on car for the BC Ambulance. I documented everything that happened, as I enjoy working as a first aid attendant and do not want to be brought down in flames due to a patient refusal form.

[JPINFV]

I feel that the patient should have been transported by our ambulance where I could have monitored his vitals, gave him O2, been able to give the worker Entonox if wanted, as well as monitor the tightness in his chest, along with the injuries he sustained on his head.

I just don't understand sometimes!!!

Why does he need supplemental oxygen?

Did he request pain control? Was it offered?

Can you do a 12 lead? If not, how were you planning on monitoring the chest tightness?

I explained to him that there may be underlying injuries that I can't see or may develop while being driven to the hospital that could not be treated due to being driven by a coworker in a personal vehicle, but that did not work.

What underlying possible injuries do you think could have developed that you could have treated?

[Richard B the EMT]

PCP, is this patient a technical boss over you in your medical office capacity?

I presume Canadian law to be on the same level as American law, that the medical person (you as the EMT or Paramedic on the scene) is medically in charge, until and/or unless there is a higher medical authority either on the scene, or in consult from the On Line Medical Control. This does not take into account a patient who signs the Refused Medical Assistance/Against Medical Advice paperwork, which is a different situation.

Is Entonox also known as "Nitronox", kind of a Nitrous Oxide/Oxygen anelgesic*, which is not (yet) in any New York State protocols, as far as I know?

Reviewing here: Took a nasty fall off a snowmobile, complains of head injuries, stiff neck, and tighness in the chest? I'm thinking possible C-Spine involvement, possible Traumatic Brain Injury, M I. Patient wants to RMA/AMA, instead of all spinal immobilization protocols being implimented (I trust you would have), O2 therapy, and patient monitoring enroute to the nearest ER. Seems like you did your best, at the time.

Just for information, you've mentioned an hour's travel time to the ER by private vehicle, and presume roughly the same with the on-site ambulance. While a critic of overuse of HEMS (Helicopter EMS), this qualifies, in my book, anyway, as a good time for the Medevac flight. How long to request the "bird", fly it in for pickup, and get to that ER?

If and when available, give us the followup prognosis.

(*Possible misspelling, I can't get the spell check to work. subject for another string)

[Bieber]

Why does he need supplemental oxygen?

While I'm right there with you on not giving oxygen unnecessarily, I would like to anecdotally say that oxygen does seem to have some therapeutic effects with regards to pain and (maybe especially) nausea. Don't know what the science says, but a little oxygen does seem to be relaxing for some of my patients.

[PCP]

Why does he need supplemental oxygen?

Did he request pain control? Was it offered?

Can you do a 12 lead? If not, how were you planning on monitoring the chest tightness?

What underlying possible injuries do you think could have developed that you could have treated?

His SP02 stats where 93% and when he was put on high flow O2 they went up to 96 %. Patient was a heavy smoker, so 93% for him was acceptable to me. I feel that the O2 would just have helped him calm down a little and bring his SP02 stats up while being transfered. He may not have needed it, but at least I could have put a nasal cannuel on him. NOt going to hurt anything.

He did not ask for pain control, but I could have offered it to him again while in transport, if I felt that the chest discomfort he was feeling was due to him being a heavy smoker and had just finished climbing back up a side of a bank about 20 to 30 meters. Not saying I would give it to him, but at least I have on my ambulance if needed.

I can not do 12 leads, but I do have a AED with 3 lead capability so I could monitor him that way. I was not concerned about his chest as I questioned him about the soreness in his chest and it was not pointing towards cardiac. I should have mentioned I did hook up our three lead and he had a normal sinus rythm.

To be honest I was not really concerned about any underlying problems that may have developed, but more so about his pain in his neck. He did take a pretty big fall. My feeling is if something did happen like, decreased LOC, sudden abdominal pain, the injuries to his head bleed through my dressings. AT least I can deal with that when we are in the ambulance and not in some personal vehicle. I could have started an IV on him, even though there was really no indication for one.

I just feel the best place for a patient who has suffered trauma is in the back of my ambulance rather than a coworkers vehicle where nothing can be done at ALL!!

Do you not agree that a patient like that should be in the back of the ambulance?

While I'm right there with you on not giving oxygen unnecessarily, I would like to anecdotally say that oxygen does seem to have some therapeutic effects with regards to pain and (maybe especially) nausea. Don't know what the science says, but a little oxygen does seem to be relaxing for some of my patients.

I just don't see why not give a patient oxygen, sure they may not need it, but if it helps them feel comfortable, or help with nausea, bring there SPO2 stats up. I was taught that any trauma patient gets a non rebreather. So that is what I did, then I down graded to a nasal at 3 LPM.