Thought provoking article in JEMS re: Patient refusals

[Nate]

EMS abuse tends to happen more in low-income areas where EMS is the doctor or a better alternative to the long lines at a clinic. Free medicine does come with a cost to the person there for it, time. Time is a big factor, and most of them do not want to wait all day for treatment. So they call for an ambulance and get into the ER and usually quicker then it would take a clinic (most of our are running about a 3 day wait that starts over every day at 0800 when the clinic opens).

While this is not the only source of EMS abuse, it does bother me that we have people who don't understand something as simple as patient refusals and why we have them. These are usually the same people who don't understand why they don't get any respect.

EMS ignorance is on both sides of the issue. We should see more articles about interesting medical problems, not reports on how we suck at our job (as in industry), or when to get a refusal, or how the refusal is being abused, etc.

Nate

[FireMedic_1979]

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.

Very good points. We should be able to tell somebody they are ok, or that it is safe for them to go to the hospital in their own car......the problem is, everybody is to afraid because the world is sue-crazy.......it's all about CYA these days.....which is what stresses many of us out.....doing things JUST for CYA, and because of technicalities....when you KNOW deep down that it is absolutely unnecesary.

[JPINFV]

Devils advocate time here. Lets say that a paramedic could refuse transport and recommend that a person transport themselves. If the patients condition deteriorates because they are transporting themselves under a paramedic's recommendation, should the paramedic not be held liable?

[Dustdevil]

While I fully agree with the concept of paramedic initiated refusal (PIR), I have only worked in one system in my whole career where I trusted every single medic in the organisation to be capable of the medical judgement necessary to safely do so. And guess what... there were only three of us. Yet we still had a strict policy of no PIR, even though each transport left only one ambulance available in the entire county.

It's a great theory. It's something to work towards in the distant future. But I challenge you to staff a large service with that many paramedics who have adequate education, experience, and intelligence to assure it is not misused or abused. With current educational standards in this country, it simply cannot be done.

[FireMedic_1979]

Devils advocate time here. Lets say that a paramedic could refuse transport and recommend that a person transport themselves. If the patients condition deteriorates because they are transporting themselves under a paramedic's recommendation, should the paramedic not be held liable?

If it's proven that it is a reasonable assessment and assumption by the paramedic that it would be safe, then no he/she should not be held liable. If it's proven that maybe there was some negligence, then yes. I dont think that a paramedic initiated "refusal" would be right....like....basically us refusing to take somebody...or forcing them to sign a refusal when the truly want to go with us......that would be wrong, after all....it is their right to call us and our job to transport if they want. However, I dont think it would be wrong for those calls that we truly feel would be safe going themselves.....then we can suggest that option to them, and then leave the ball in their court....their decision.

[brock8024]

This has to be the most stupid thing I have read in a long time. They are clearly bashing medics for something that even doctors do. You can not tell me that every doctor in this world always with 100% makes the right diagnoses every time. Even with all of the fancy test and stuff they still miss things. Hell I worked once and they had to call a patient back in cause the doc missed a pneumo. So why should medics be put under the microscope. We do the best we can do just like the doctor and nurses.

The one story was stupid for trying to sue. I mean his mom was fully aware of the stuff apparently she was ready to die and knew she could. Nothing we or anyone else could do. That it seems like does not count. The other ones I do not know. Like I said not even a doctors are right 100 percent of the time.

If the medics would have transported the patients against their wishes we would have been reading on Assault and battery of patients and kidnapping. So like many others have said damn if u do damn if u do not. It just makes me mad that they pick at medics and things but never there doctor friends that kill patients every year. There is a good topic the number of patients doctors kill or the number of mess ups they make.

Brockie

[whit72]

So meanwhile while you are transporting this "toe pain or toothache...etc." you have a MVC, pediatric arrest, true AMI patient.. be sure to tell them why your additional 15 minute response time was warranted.. because you were on a non-emergency patient and they deserved to be transported just as much as their loved one. Anytime, you are able to place or the patient warrants setting in the lobby for triage, abuse occurred, and apparently EMS was not needed or justified. The patient could had and should had went by other means.

Another im to good to transport a broken toe. DO you tell them I cant transport you because what if a pedi code comes in.... So you determine who is having an true MI and who isnt, do you leave the one not having pain, or dosent have any elevation, cause im sure that never happens. Do you carry your little traponin test kit on your belt. Well maybe that pedi code comes in when you are arguing with the pt that this is not a true emergency, how long do you wait there trying to convince them not to go to the hospital, gimme a break dude. OH wait I didnt see the cct paramedic near your name, my bad your god.