Save 1-2 million patients in 2009 ??

[JPINFV]

I agree, facts are an important thing, but unfotunately, as stated many times, EMS is not required to report these errors, so the only ones we know about for sure are the ones that resulted in a lawsuit that was publicized in the media.

These errors? Isn't it a little presumptuous to think that all AMAs that worsen or die is an error? Isn't that like saying a patient who dies under a DNR order is failed by the medical community? After all, both represents a refusal to accept medical care. Alternatively, are you suggesting that we start to kidnap patients who refuse medical attention?

[HellsBells]

Ok, in response to your question of what would we suggest to fix the problem (which I'm not sure even exists in the first place), I guess we could all start protocols stating that we transport all patients, no matter what the compliant.

Some services do have that policy. However, start doing things that way and we have a number of other problems. For one more ambulances are tied up transporting patients unessesarily. The EMT's and Paramedics get burnt out faster, because management places no value on them and they don't use critical thinking skills, it just becomes a you call, we haul mentality. Emergency rooms get backed up with all the non-emergency patients that EMS has brought in and crews get to sit in the hallway all day or night with the patients they have brought in for no good reason.

Not a good way to do business in my opinion.

Actually, the real solution (and its been mentioned on this sight many, many times) is better education. Prevent the medics and EMT's from getting burnt out in the first place. Have a hiring process that hires competent and educated medics. Make sure continuing education programs are in place to keep employees up to date. Fire people who can't or wont keep up with training and continuing education. Furthermore, let the Paramedics do their job, if they are trained properly there should be no need to call a supervisor for every refusal.

Oh and one more thing, specious statements like "just one death is to many" are completely meaningless.

[crotchitymedic1986]

Good suggestions, and I am not advocating transporting everyone, for the same reasons you sited. Which is why I suggested the supervisor model. If the supervisors were willing to do it, what would be anyone's problem with it then, as it would only help protect you ?

[WolfmanHarris]

I'm not going to say "saved lives" in this post as I believe that narrow a definition is incredibly difficult to examine with the record keeping available. Now if we want to talk about medical errors and the complications or worsened outcomes they cause, that's different. That involves less necessary proof. Take for example Kaisu's recent case, despite the medical errors made by the FD medic in that case, Doczilla's opinion is that the Pt. was likely going to die regardless. So we can't with certainty say that the medical error caused a death, but we can say it complicated the situation.

So would having a supervisor present at a refusal result in decreased medical errors. Maybe. But I don't see the supervisor showing up, doing another thorough assessment or anything else medically relevant. So their role becomes to flex muscle and make things look serious. I can see the odd patient responding to being overwhelmed by opinions, but I can also see patients digging in their heels with a crew that they've refused transport from hanging around waiting for a supervisor to come in. Don't you think we'd accomplish more by ensuring that providers are educated in refusals and am able to fully inform patient's of the risks and take the time to try to convince them. The flip side of this being that when the education is there, not only will EMS realize the importance of convincing some patients to accept transport and treatment but will then be able to refuse that transport when warranted.

For the life of me I cannot remember where I read the study reference or even if it was a peer reviewed study, but I read somewhere that when Pt. were fully informed of the risks associated with refusal and given time to reconsider, many changed their minds and accepted transport. I will keep looking for that study, if it exists. In the meantime here's a quote from a Jems article (not the best source sometimes I know) I found in the same google search.

Managing patient refusal

Members of the Dallas EMS system developed the Parkland Protocol to deal with refusals more efficiently. The first step is to determine the patient's emancipation status based on state laws. Second, the provider must determine the level of competency or consent based on the three categories of voluntary, involuntary and implied. Parkland Memorial Hospital provides 24-hour legal counsel to help obtain permission and to support the medical director's decision.

Tips to avoid refusals : First, always attempt to establish a good rapport with your patient. We must remember that we can often be battling unseen forces, such as negative feelings toward hospitals, the medical profession or insurance companies. Showing a friendly and helpful face to the patient could make the difference when you must try to convince them to go to the hospital for their own good. Try to find a balance between what's best for them physically and what they're willing to agree to mentally.

Second, remember to contact online medical direction when you have a difficult case and then document it. Talking to a physician has been proven to change some patients' minds.

If, however, the patient still refuses care or transport, make them aware of all of the risks and rewards of treatment and non-treatment as necessary in implied consent, complete a patient refusal form (usually located on the back of a standard PCR), and obtain the patient's signature. Document your medical opinions and the patient's reasoning and steps taken to convince the patient to accept treatment and transport.

Finally, encourage the patient to seek health care immediately if certain symptoms worsen or "if any of the following happen," and then give them a list of symptoms.

Always put the patient's welfare first.

JEMS article

As for medication errors, that's a different situation all together and won't be solved by having a supervisor on scene and perhaps should be left to another discussion as they're very different animals.

- Matt

[HellsBells]

If the supervisors were willing to do it, what would be anyone's problem with it then, as it would only help protect you ?

I have a problem, because its a bad use of resources, and it wont be needed, if the EMS service takes the time to unsure they have hired the proper staff. Supervisors have other jobs to do besides babysitting crews. Not only that, how on earth can a "supervisor" render a valid medical assessment over the phone?

[JPINFV]

I guess if we made everyone a supervisor...

Alternatively, if a supervisor comes on scene to "convince" a patient to go to the hospital or overrule a patient's desire to refuse medical care, then that supervisor will be the one teching that call.

[Dustdevil]

If the supervisors were willing to do it, what would be anyone's problem with it then, as it would only

help protect you ?

The problem is that your solution is short-sighted and does not address the root cause of the problem, while also greatly increasing the cost of EMS provision. In other words, there is nothing good about it.

Get rid of fire, thereby elevating educational and intellectual requirements in EMS, and the problem will fix itself, as well as costing less.

[crotchitymedic1986]

My solution doesnt increase the budget by $1.00. You already have supervisors, and as stated they could call the patient via the telephone, they would not have to come to the scene, unless they chose to. We are not talking about every call, just the so called "refusals", which should be a small percentage of your daily call volume. You already have a supervisor(s) on-duty, they would just have to make a few more phone calls during the shift.

And this is not referenced to the last several respondents, but could it be that some medics would not want that supervisor oversight, which may make them transport more patients then they normally do ?

If you are documenting that a patient is refusing AMA, isnt it prudent to try to do everything to try to get them to go ?

But like I said, I am open to suggestion for a practical solution, that can really be implemented.

[WolfmanHarris]

I think you're missing the point argued by most on this one Crotchity. No one's really arguing that the supervisor should be kept in the dark, or away from the scene b/c they're all afraid of being found out to be lazy incompetents. What's being argued is that the Supervisor is a blunt instrument that may or may not address this problem, while proper education of the provider and proper informed consent of the patient solves multiple problems. In the end there will still be refusals that should go to the hospital, but like has been said before, people have the right to be stupid no matter how sick it makes them. We can only seek to reduce these and prevent inappropriate refusals. Increased supervision won't solve the problem of lazy incompetent providers, it will only force them to seek out other avenues to avoid work.

[Dustdevil]

It does increase costs, because more supervisors would be needed in many places. And those supervisors would be burning a lot more gas too.

And that ignores the fact that supervisors are not necessarily any better educated medically than anyone else on the street, and therefore no more competent at making that patient assessment.

An ambulance is like an airliner. There is a self-sufficient crew operating it, and they don't need supervisors to respond to tell them how to handle a routine situation. If they do, your system sucks. Fix the system. Your solution just puts a Band-Aid on it, which is retarded.