Who is responsible for your patient?

[DFIB]

A recent thread about a man that died after a ski accident has brought a question to mind. The details of this call are unclear in the media and a subject to a lot of speculation.

Once a patient is in our care can the family member/bystander intervene in the patient care and treatment contrary to the attending medics running diagnosis and treatment plan?

What would you do if the accompanying family member attempted to take over the care and treatment of your patient while in the ambulance?

Dwayne, would you put a question mark after the thread title? Thanks.

Edited for spelling and to ask Dwayne to include a question mark after the thread title.

Edited February 10, 2012 by EMT City Administrator

[systemet]

Once a patient is in our care can the family member/bystander intervene in the patient care and treatment contrary to the attending medics running diagnosis and treatment plan?

It's difficult to give an absolute answer to such a broad question, but, in general, no.

I'd be an idiot, as a paramedic, if someone walked up to me, and said "I have 8 years as a CCU nurse and I believe my wife is having an MI", and I didn't at least listen to that, and consider the implications, and get their opinion about the clinical presentation. But they shouldn't have a need to intervene in the care, because I should know how to treat an MI with the equipment in my ambulance. It shouldn't be necessary. [Not speculating about the ski hill event here, because I don't want to.]

If a physician was to show up and want to perform some sort of hypothetical surgical procedure that's outside of my scope, then we can discuss it, they can be advised as to the limitations of the equipment on the ambulance, and we can have a talk with the med consult doc. But it's also hard to picture this situation happening.

A family member? A polite discussion. I'd ask them to stop. I'd explain what I was doing, and why, and why whatever they wanted to do wasn't possible, or safe.

Absolute worst case, they want to do something clearly unreasonable and are screaming and throwing shit around? I reluctantly call law enforcement. If I believe my personal safety is at risk, we pull the ambulance over and they get asked to leave. They can do that vertically or horizontally at speed, their choice. But this situation is highly unlikely, and represents a complete failure on my behalf to effectively communicate, which is basically the cornerstone skill of being a paramedic.

People don't have to respect us. They don't have to be polite to us. And they get an extra special pass on this when a loved one is critically ill (think about any critical ped call that's ever gone pear-shaped). But they do have to not get in the way. Asking someone to leave shouldn't be done because they're annoying, or disrespectful, or verbally abusive. It should be done because they're presenting an active threat to safety, or actively interfering with care, not just getting on my nerves.

I've told family members they can't come in the ambulance, because the situation is suspicious for abuse. I've asked them to ride up front, and I've tried to arrange alternative transportation for them when the situation is critical, e.g. an evolving STEMI, trauma code, etc. But I've never had to pull over the ambulance and tell a family member to leave.

[i have pulled the ambulance over on occasion, and told people who are being abusive that if they no longer want my help, they're free to go, but this is a very different situation.]

Edited February 10, 2012 by systemet

[ERDoc]

What would you do if the accompanying family member attempted to take over the care and treatment of your patient while in the ambulance?

Pull over and leave them on the side of the road.

[jonas salk]

Family always* rides up front and as such it's physically impossible for them to interfere in patient care.

A few years ago I had a snowmobile vs tree call. Two guys were out having fun, one miss judged something and ended up hitting a tree at around 100 km/h. Severe chest wall trauma; pt was vsa when we arrived. HIs snowmobile friend identified himself as trauma fellow and insisted that we transport his friend. He was unable to produce id, but i took him at his word that he was a physician, i asked him what the prognosis would be for a patient with similar traumatic injuries who was 25-30 minutes away from a trauma centre, he agreed that it would most likely be called when we got there and accepted our field pronouncement.

Personally I find that if you act professionally and discuss the situation with the family member who identifies themselves as a HCP that usually reason prevails. It also gives you the opportunity to gauge if they're full of shit or not as a lot of people like to identify themselves as HCPs regardless of their educational background (or lack their of).

I also remember a situation a few months ago (thankfully i was just first response on this one), where a woman called 911 for her 13yo daughter because she was in SVT. Long and short of it is, the mother is a cardiac tech, her daughter had WPW in few months prior, had successful ablation, on this evening the daughter was a little jittery (admitted she had a 5 hour energy drink earlier in the day). When the daughter by herself she was in a a sinus tach at about 110, as soon as her mother would come back she would jump to 125. The mother kept on panicking and it made the daughter freak out a little as well.

Once the transport arrived, the mother obviously insisted on coming in the back of the truck but she also had her 6 year old son with her, so the as a safety compromise the mother rode up front and the son in the captain's chair. This also had the added benefit that the daughter was separated from the nervous mother.

*If the patient is a paed then I will allow a family member in the back.

[runswithneedles]

A recent thread about a man that died after a ski accident has brought a question to mind. The details of this call are unclear in the media and a subject to a lot of speculation.

Once a patient is in our care can the family member/bystander intervene in the patient care and treatment contrary to the attending medics running diagnosis and treatment plan?

What would you do if the accompanying family member attempted to take over the care and treatment of your patient while in the ambulance?

Dwayne, would you put a question mark after the thread title? Thanks.

Edited for spelling and to ask Dwayne to include a question mark after the thread title.

As far as our protocols are concerned it must be a physician that shows proper Identification and licensing. And also agree that he takes full responsibility and liability to the outcome of the patient regardless of what it may be.

However, when it involves the family member of the patient as being a trained healthcare professional. If I have no pertinent medical reason for that person to be in the back of my box (which in inter facility pretty much narrows those reasons down to if it is a child/ opposite sex adolescent or the family member is bi lingual and my patient is spanish speaking only) I tell them for insurance purposes they must ride in the front and Ill keep them posted on how they are doing.

And in the god awful event that it hits the fan and that family member tries to intervene we will have him/her taken off the box and leave her on the side of the road.

Edited February 10, 2012 by Mike Ellis

[paramedicmike]

Once a patient is in our care can the family member/bystander intervene in the patient care and treatment contrary to the attending medics running diagnosis and treatment plan?

They think they can. Some will even try. They will be shot down politely, professionally, yet firmly.

What would you do if the accompanying family member attempted to take over the care and treatment of your patient while in the ambulance?

Close the door between the cab and the box. The family member will be up front. The patient will be in the back. They will not ride together.

As Mike mentioned, if it's a physician who can produce proof of identification and licensure (many States have a wallet card for physicians. Do you know what your State's card looks like?) and is willing to assume care AND ride to the hospital AND stand there to explain to the ER doc what's going on I'm happy to consider it. This is up for evaluation on a case by case basis and I reserve the right to refuse any or all family members from riding in my ambulance.

Every effort will be made to allow a family member to ride up with us. Many times we encourage the family member to drive so that they have transportation available if/when their loved one is discharged (but will take them with us if that's what they want). But if they are meddlesome on scene and attempting to drive care they get shut down pretty quickly.

[island emt]

Our state protocol book has a page specifically for this .. [ paraphrasing] : To medical providers. If you wish to intervene in the care at emergency scene, you must accept responsibility and travel in the ambulance to the hospital. You will be the attending physician.

WE have had Dr's , PA's NP's happen on to a scene and offer to help. No problems with that. But if they want to go outside the scope of the state protocols then they must assume responsibility.

[DwayneEMTP]

I agree with all up to the point where a ped is involved.

Legal age to consent then I don't have to follow the family's plan, unless their plan is better than mine, which has happened a couple of time while transporting chronically/critically ill pts.

But with a ped the folks can have a significant impact. I'm grateful that I've never had this happen to me, but know other medics where it has. And it can really suck. I mean, I've had parents try to intervene with my care of their damaged child, but as stated by System, they were out of their brains with pain and grief and it just took a few mins, some compassion and explanation to get them onboard.

But in the situation from the article, it's hard to imagine that they couldn't have managed that better. But then again, they had a critically injured patient, and depending on her behavior all along....who knows. But again, as System said, regardless of the woman's behavior, the medics should consider that solution a massive fail on their parts. Perhaps they did their best, but their best wasn't good enough this time...

Dwayne

[tcripp]

Although my experience is limited, I have yet to have a family member try to direct my treatment plan. The only thing I can think of on my behalf is that I explain what I am doing and why to those around. Now, I have had my fair share of patients direct their own care, but that is their prerogative.

I am getting better about having family ride up front instead of in the back (something about liability and safety seems to make that a non-issue), so I guess I'll just have to play it by ear if it does happen.

Toni

[DFIB]

I think that we all are willing to accept a helping hand. I know that I have accepted help from bystanders and have even recruited them to help hold pressure on a hemorrhage, but I direct the care. For example when doing CPR on scene I will always ask bystanders if anyone knows CPR and if they do not I recruit someone to watch me because I may need their help. I have never actually switched with a bystander but do consider it a possibility. Once again, I will direct the care.

I listen to patients and the family because they often know patients situation. I don't think I would let someone else take over the care of my patient unless know that they can exceed my level of care. After all, they are my patients and I have a duty to act, which includes being my patients advocate in the face of a good willed patient that may or may not injure my patient.

I don't know if i would leave a wife on the side of the road, I have never been faced with that situation, but I am very clear of who I am responsible for. The patient would have to come first.

Edited February 11, 2012 by DFIB