Thought provoking article in JEMS re: Patient refusals

[Just Plain Ruff]

http://jems.com/Columnists/emslaw/articles/15830/

This made me think. It's a two parter so make sure you read both.

[Dustdevil]

Just now getting into the first article, but I already found something I really like.

A series of studies conducted in different areas of the U.S. have shown that EMS providers are incapable of adequately evaluating patients to determine whether alternative means of transport may be appropriate.

Well, no kidding! And by extrapolation, I believe that also tells us they are incapable of adequately assessing whether or not the patient needs ALS or not!

Back to reading...

[Just Plain Ruff]

that was one of the things that jumped out at me. I mean it's one thing to treat and street a laceration on the leg or so but another thing to not transport that lady.

Case in point.

Had a lady original call was for chest pain. On our arrival patient with absolutely no symptoms.

Had a high suspicion on this one but I could have let her refuse. I didn't and I transported.

We were driving down the road just off her driveway and she coded, I said Holy crap batman. worked her got her back. Took her to the ER and she coded 3 more times. We flew her to the cardiac center and she was having a right wall/posterior MI. they cathed her.

I called her house hoping to talk to her husband 5 days later and guess what

She answered the phone. what a feeling

[nsmedic393]

As far as the examples given in the article they seem quite common sence to me. One thing to be sure is that not everyone posesses common sence. Patients presenting with SOB, altered LOC and other possibly life threatening condition need to go to the hospital, its just that simple. Who the he11 are we to try and talk someone out of getting medical attention.

Refusal to transport by EMS should never be allowed, it may help with some of the BS calls that tie up our systems so much but this is the result, idiot medics that are more concerned with getting off on time than treating their patients. Makes me think that there should be a supervisor present for all non-transports.

Cases such as these are just annother example of the laziness, incompetance and stupidity that is so prevelant in our job today. No wonder we can't get any respect. :evil:

[UMSTUDENT]

See I hold a difference of opinion when it comes to refusals, especially because I've seen my share of absolute bullshit calls. I also feel paramedics, properly educated paramedics mind you, are perfectly capable of determine when someone does not need to go to a hospital by "emergency" means. This is all within reason of course.

For instance, why should someone with a laceration to their finger need to go the hospital unless it requires stitches? Hell, if we would raise the standards and educate our providers properly we could probably administer a tetanus and suture in the field. Now if a patient REALLY wants to go to the hospital, that's another thing all together. Chest pain in a patient over 35 (our protocol), with family history, abnormal risk (obesity, etc), trouble breathing, etc should definitely ALWAYS be transported ALS. So should someone with a hole through their abdomen. DUH!. I think there a lot of doctors out there who might advocate for a world without massive amounts of radiation. Everyone doesn't need to have a full body scan to diagnose a problem or we'd have everyone in medical school specializing in radiology.

I believe, without data to back it up of course, that a properly educated paramedic could tell people they're going to be OK once and awhile. Mothers have been doing it to worried children for thousands of years with injuries a lot more severe than the cut finger I see once and awhile. When I was a kid, there were plenty of times I probably should have gone for stitches and didn't. A lot of those times, judging from my experience, would have been socially acceptable ambulance rides in our current culture. Getting in the car and having your wife drive you to the hospital that is 10 minutes away isn't going to kill you either if you're having gas pains.

When I was a kid and I told my mother this, do you know what she said? "Fart!" Our culture has allowed people to become babied. If a paramedic doesn't take someone to the hospital for a laceration and they develop an infection because their too damn stupid to use antibacterial soap the paramedic is held responsible. We no longer expect people to take care of themselves.

Personally if your having chest pain, trouble breathing, a traumatic injury, or sudden, severe onset of pain or weakness for no apparent reason you deserve ALS transport ALL the time. This isn't normal by any means and something, most likely something very, very bad, caused it. If you cut your finger, or aren't "feeling well" for the last three days you can get in the car or call a taxi and go to the hospital.

Every patient should be allowed to go for ANY reason they want, but when they ask "What do you think?" We should be able to say, "Well man, I think you need to go sit on the toilet and make a bowel movement."

This system is for immediate life saving care. We are not WebMD, nor the local social services.

[Dustdevil]

For instance, why should someone with a laceration to their finger need to go the hospital unless it requires stitches?

Because a lot of people faint at the sight of their own blood. Some people faint at the very thought of their own blood. I've seen it hundreds of times. If they do that while driving to the clinic, after you told them they could, the liability is on you.

[UMSTUDENT]

Because a lot of people faint at the sight of their own blood. Some people faint at the very thought of their own blood. I've seen it hundreds of times. If they do that while driving to the clinic, after you told them they could, the liability is on you.

Have someone else drive you. People have friends-call them.

If it's bleeding so bad that you can't deal with it for a few hours with direct pressure then yes, you should go via ambulance. That is a serious problem. There is also no way that a paramedic can tell if someone has some psychological issue with blood. Certain amounts of blood loss will not kill you through physiological means. Besides, no paramedic should let someone refuse if they are profusely bleeding. They let them refuse once the bleeding is under control and THEN drive to the hospital. If the patient thinks they can handle it and signs a refusal, by all means they should be able to drive and save themselves a 600 dollar bill.

Our culture is defective in my opinion the very minute we associate blame with a paramedic because someone can't handle the sight of blood. At that point in their life, 16 or so years old (when you can drive), they should be able to know if they can handle the sight of blood.

As far as fainting at the immediate sight of blood and going unconscious-How in the hell are they going to activate the system if they're at home, by themselves on the floor unconscious? They won't! There had to be some conscious, free will and volition utilized in making the decision to call 911. Paramedics come, clean-up the wound, put a bandage on that covers the injury and let them make an informed decision on whether or not they want transported. Sorry, I find the previous notion absolutely ridiculous.

[Dustdevil]

Obviously in your limited experience you have never encountered the people I am talking about, because you clearly do not understand. They don't have to be losing a lot of blood. It can be extremely minor. And they commonly do not pass out immediately. It is often times a delayed reaction. And it happens probably more often in adults than minors.

A properly educated medical professional knows this and takes it into account when evaluating his patients.

Yes, to hold EMS responsible for all of this is absurd. But if you don't understand that absurdity gets you sued as easily as malpractice, then you didn't read the article.

[UMSTUDENT]

Obviously in your limited experience you have never encountered the people I am talking about, because you clearly do not understand. They don't have to be losing a lot of blood. It can be extremely minor. And they commonly do not pass out immediately. It is often times a delayed reaction. And it happens probably more often in adults than minors.

A properly educated medical professional knows this and takes it into account when evaluating his patients.

Yes, to hold EMS responsible for all of this is absurd. But if you don't understand that absurdity gets you sued as easily as malpractice, then you didn't read the article.

Oh? I've seen it and yes I understand that it can happen with very, very little amounts of blood. Well known psychological event called hemophobia. The fainting reaction you speak of is commonly associated with a mini panic attack that people experience at the sight of blood. Blood pressure increases, heart-rate accelerates, hyperventilation (absent in the case of a parasympathetic response) occurs and the person eventually passes out. Depending on what theory of psychology you speak of, this reaction is most likely "learned." From a basic Freudian prospective, the patient probably associates the blood with danger which would make complete since seeing as most injuries, which are in fact dangerous, occur with some exposure to blood.

Unfortunately for EMS providers, this reaction can occur to any number of the hundreds of documented phobias. Using your "theory," if a person has arachnophobia and has seen a spider they should probably be transported to the hospital. The only support I can see for the argument is that hemophobia is decently prevalent, and like most psychological traumatic experiences, can have a sudden onset. Again, people have friends...have them drive you. Also, AGAIN...this is the patient's choice.

You also know nothing about me and sound extremely pompous making wild claims about my level of experience. I clearly do understand.

The fear of refusals in this industry seems to be founded more in the fear of taking responsibility. I'm guessing that's why most of us don't become doctors. How dare we ask the paramedics of the world to learn the diagnostic criteria to make educated judgments about the current medical state displayed by a patient.

We do not need to tell every patient they need to go to a hospital. Tell them the truth, tell them what you think! I'm not talking about paramedic initiated refusals but instead giving the patient all the facts in regards to what is truely going to happen.

[Ridryder 911]

What a bunch of B.S. !... That the court sided with the son... If the EMT's had taken her in the next thing you read would be "EMT's charged with kidnapping!".. It is a no -win situation. THe problem was the EMT's did not do the paperwork right... once you inform them of the potential risks, and hazards and IF they are alert and responsible enough to understand such risks, then they can and have the right to refuse such treatments and transports.. If the son was that damn worried, he should had power of attorney!... It is a shame the medics poorly documented.. and could not had counter sued the family. I wish more medics would start suing the families of those that charges and false claims. Maybe there be less ambulance chasers.

You can only do so much.. you can inform them, you can be nice and suggest, but I be damn if I will wrestle them to take them to the ER. I don't know how many post seizures I took in, only to AMA as soon we entered the ER door. Even, had ones threatening to sue, when they awake, if I did not release them now!...

Again, it is a never a wining situation.

R/R 911