Ethical Question: Refusals versus Not Needed

[Chief1C]

"No patient found"

[spenac]

How do they legally define that line of what should and shouldn't go by ambulance? Is it possibly that a pt could look and through a good assessment look okay but they really are not be? Are there silent killers out there? How do you draw that line? The way I see it is it is better to lean on the side of caution and transport. Their definition of an emergency is different than ours. The emergency is in the pt perception.

Speedy some common sense comes into play. Most callers will still be transported if they want to go. Now in saying that the guy that stubs his toe, even if broken toe does not need an ambulance 99% of the time, and the 1% of they time they would need the ambulance their other vitals would tell you they need to go. The caller that you get that just wants a ride for lunch or the store near the hospital and even tells you that is what they want. They do not need to go. The caller that can't sleep so decides they want to be checked to see if they have a cold since they sneezed once last week does not need to go. I refuse to be a complete taxi. Yes often the illnesses and injuries we transport could safely have gone other means but again any doubt you go ahead and offer transport. Guy has indigestion after eating spicy food, maybe even though 12 lead is good might be in early stage of heart attack so you transport. There are no 100% in medicine, no matter what level you practice at.

It is time that EMS wake up and start treating people but also sending them to other places besides ER and by other means than ambulances when it is not an emergency. And if they say they have no other means to get there sorry to sound calloused but not my problem, they need to get a friend or pay a real taxi to take them to the store by the hospital.

As to what they call emergency and what we should call emergency means we educate the patients and at times that education should include saying no. If we talk till blue in the face about what really needs an ambulance and then still transport the only thing they learned is to call us for a free ride.

[speedygodzilla]

Speedy some common sense comes into play. Most callers will still be transported if they want to go. Now in saying that the guy that stubs his toe, even if broken toe does not need an ambulance 99% of the time, and the 1% of they time they would need the ambulance their other vitals would tell you they need to go. The caller that you get that just wants a ride for lunch or the store near the hospital and even tells you that is what they want. They do not need to go. The caller that can't sleep so decides they want to be checked to see if they have a cold since they sneezed once last week does not need to go. I refuse to be a complete taxi. Yes often the illnesses and injuries we transport could safely have gone other means but again any doubt you go ahead and offer transport. Guy has indigestion after eating spicy food, maybe even though 12 lead is good might be in early stage of heart attack so you transport. There are no 100% in medicine, no matter what level you practice at.

It is time that EMS wake up and start treating people but also sending them to other places besides ER and by other means than ambulances when it is not an emergency. And if they say they have no other means to get there sorry to sound calloused but not my problem, they need to get a friend or pay a real taxi to take them to the store by the hospital.

As to what they call emergency and what we should call emergency means we educate the patients and at times that education should include saying no. If we talk till blue in the face about what really needs an ambulance and then still transport the only thing they learned is to call us for a free ride.

I see your point, and also see potential for abuse in refusing pt transport. I have transported very stupid things to the hospital and seen even stupider things check in at the ER. This is definitely a chance for a teachable moment.

If this guy who breaks his toe is refused by us and gets an infection and low and behold dieing from this infection due to delayed care while he tries to find a ride. No money for a ride, no family or friends, no transportation besides his broken toe. Or the pt decides oh I'm okay they didn't want to take me to the hospital I don't need to be seen than. When he dies this could become you problem. This will probably never happen, and I totally agree with you as to this not being an emergency, it just seems like a possible legal mess. At least make sure that documentation can be made that they are going to see a doctor by private vehicle/other means.

EMS is not all just emergencies as we all know. Remember that you are not a complete taxi and that we do treat people that really do need us and also appreciated it at times.

[Don1977]

If a patient refuses I usually ask them at least 2 more times "you sure you don't want to go to the hospital". I tell them if they change there mind to call 911.

I have never forced a refusal on someone, I have transported them to a closer hospital due to traffic or close to end of shift.

[Just Plain Ruff]

but if that fractured toe throws a marrow emboli to the lungs and the patient dies, what happens then? hey it could happen.

[crotchitymedic1986]

Before this gets into an arguement about who should or shouldnt be transported: I am really not too concerned about the 1 in 10,000,000 patient that dies from the infected cut or the embolus from a toe fracture. To clarify the original question:

Regardless of whether both medic and patient agree that transport is not needed, or if the medic talks the patient who needs to go out of transport by EMS, once it is determined that transport is not needed by EMS, is it ethical to then have the patient sign a form that states that they refused EMS care AMA and release the EMS agency from any liability ?

As many have stated, this form is basically used for EMS CYA purposes, which is fine in a true AMA refusal where the medic did everything humanly possible to talk the patient into transport. But the vast majority of no-transports are not true AMA refusals.

[under-dreaming]

My reasoning is probably based on the fact that I haven't been in the system for very long at all, so perhaps I don't mind so much due to not as many ridiculous encounters... yet.

I don't think it is ever ever necessary to take it upon yourself to tell a pt. that they don't need an ambulance and then have them sign a paper releasing you of liability when in fact it is your words that created that situation. If a capable adult does not want to go to the hospital, even if they did not activate the EMS system, we have been trained to inform them of the implications and essentially release ourselves of liability. That is the only way that I want to do it. That is the only way EMS providers should do it.

If someone can give me an example of how these "unnecessary" pt. transports hinder and endanger the EMS system within your work area, I would like to see the evidence and then stand corrected accordingly. Also, we must remember that it is often these "unnecessary" pt. transports are the bread and butter of this business. Frequent fliers need to be dealt with after the fact. Try to talk to them en route about their habitual abuse and refer them to alternatives, if there are any. Perhaps the family or the hospital can also be of assistance in these matters.

We see the articles from time to time regarding mistakes involving pt. care (more appropriately the lack thereof). We mustn't allow ourselves to develop these dysfunctional habits. Eventually we will fail the patient if we take these situations lightly.

[crotchitymedic1986]

You need to work in a busier urban 911 system to understand how the low acuity calls hurt the system. In a nutshell, you have more calls than you do ambulances, and ambulances get tied up on low-acuity calls, and the system runs out of ambulances for several minutes or hours of the day. You may work in a rural area where typically, the people who call 911, are atleast sick. In the urban setting, you have a much different call volume, where people abuse EMS, and the EMS has to be the back-stop for all of the nursing homes, sporting events (amatuer, child, and pro), doctor's offices/clinics, and hospitals when the convalescent ambulances are not available --- but traditionally it is the poor, the drunk, and the stupid citizens who call 911 for anything and everything.

[crotchitymedic1986]

Read zzyzx's post about Washington medics in trouble --- bet they got that guy to sign a REFUSAL.

[under-dreaming]

Read zzyzx's post about Washington medics in trouble --- bet they got that guy to sign a REFUSAL.

Already did. That was exactly what I had in mind when I was writing the comment. We can never be too careful, that's what I try to remember in those situations.