Politely telling a patient "no"

[Riblett]

You are called for a sick person, dispatcher advises "fever". You are a ALS EMS service in rural area.

Upon your arrival at the residence you are made to wait outside for a few minutes until someone comes to the door. Once inside, the patient's husband very casually leads you upstairs to a bedroom. You see a 54 y/o lady sitting in a chair in no apparent distress. There are two RN's (home health nurses, affiliated with the local hospital) doing a dressing change on a foot ulcer. The husband tell you that she has a fever and needs to go to the ER. One of the nurses tells you that they still have to finish doing wound care and then have to put her wound vac on. You'll have to wait. They won't even let you access the patient to assess her or take vitals until they are done and they say it is going to be a while.

The lady is alert and oriented, in no apparent distress, advises that she has no complaints except for her foot hurts, but that it hurts all the time. She wants to be taken to the ER in the neighboring county (an hour away.) You are the last ambulance in service in the south part of the county. How do you proceed?

This was a call from last week. We had to wait 35 minutes for the nurses to finish before transporting her to the ED an hour away. When I suggested that a convalescent scheduled transport ambulance service might be a better option, considering she was not ready to go and her low level of distress. I don't think a 911 ALS ambulance was appropriate, and when I tried to explain that to them, her husband became irrate. I think my view is tainted, but I don't think most people would expect a 911 paramedic-level ambulance to wait over thirty minutes for you to get ready for a non-emergency BLS transport to a hospital in another county. I would think that the nurse at least should know better. I am not saying that she did not need to go to the ED or at least be seen by a doctor. She is probably septic, but she has had the fever all day and has no complaints. Even though she did need some assistance getting down the stairs, but a BLS transport ambulance and/or RN's could definitely handle that.

How would you handle this situation? Does the service you work for have any policies for this type of call? Would you wait 30 minutes for this lady to be 'ready' to go on her medical taxi ride in your ambulance with you service area already stretched thin?

[Fox800]

Get a supervisor involved. Did the nurses physically block you from accessing the patient? If so, a little talk with them and their supervisor is in order. I am guessing that your system doesn't use BLS units, that would be nice. If a patient is refusing to allow you to assess/treat/load/transport them "I'm not ready", perhaps you can go back in service on your own...while you wait. The patient is refusing to allow you to care for them. That way if an emergency call drops, you can respond.

This is a good chance for public education/spoon feeding on proper use of 911.

[EmergencyMedicalTigger]

I agree, contact a supervisor. Ask the patient if she wants to be taken to the ER by ambulance. If she says "yes," then explain to her you need to leave now. It's an emergent 911 service, so you can't wait on scene that long. Advise her, you would be more than happy to take her to the closest appropriate ER, but you're not passing up a hospital to take her to one an hour away. If the patient wants to go with you and the nurse is refusing you patient contact, then call PD.

[VentMedic]

Missing a few things that could be important:

54 y/o with an ulcer requiring a wound vac? And home health RNs?

What is her medical history?

Meds?

What stage is the wound?

Did she have a flap done that required microsurgeons at the other hospital?

What was different about the pain that prompted the call?

She is probably septic, but she has had the fever all day and has no complaints.

If that fever is an indication of sepsis, she is a ticking time bomb who could go bad quickly depending on the rest of her medical history.

How soon would the other scheduled transport ambulance have reached her?

Does you ambulance also do non-emergency calls and if so how does your service advertise itself in the phone book?

I can see the husband's reason for being irritated if you have not assessed the patient or did not have much more than what you have provided here for information. That could be taken as a "just don't wanna do the call".

I do however disagree with the nurses making you wait and they should have gotten things organized prior to calling.

[Riblett]

The lady had a history of skin cancer, which had been treated with at home chemo by pill. She was no longer doing the chemo. Also a history of high cholesterol and hypertension for which she took HCTZ and a cholesterol drug (I don't recall which one). No diabetes, cardiac history or heart problems. I looked at the nurses' paper work which indicated that it was a stage 2 ulcer. I am not sure what surgical intervention was required for the foot, but she wanted to go to the ER because she had a fever. Not for the foot. The home health nurses were there as part of her regular biweekly wound care.

The nurses told us that we could not assess or transport her until they were done. When I was told that, I did not attempt to force by them or anything. The BLS transport ambulance could take anywhere from 30 minutes to about three hours if they are really stacked. But that is really the exception rather than the norm. She is able to stand and walk to the bathroom and around the bedroom with her husband's help. I think she really could have gone by car, especially with a wheelchair. It is of course possible for her to have a terribly drastic change in her condition and need an ambulance, but with that logic one could argue that all headaches need a brain surgeon and all every sniffle needs an ENT doc.

As far as the hospital choice is concerned, we deal with that sort of thing all the time. Our local ED is pretty basic. The expectation from the family and nurses that we should wait thirty plus minutes for them to get her ready, and take her on a BLS taxi ride 40-something miles away, and then getting mad about it was what I took issue with. What is the PC way to tell them no?

[Fox800]

Reiterate the fact that the caller felt that this was important enough to call 911, and that means that you are expected to perform your duties as a paramedic. This includes accessing and evaluating the patient as soon as possible. If the nurses refuse to let you interview the patient, get vital signs, HPI, SAMPLE, physical exam, etc...then they are interfering with your duties...your duty to act began when they dialed 911. Prompt supervisor involvement, probable involvement of the nurse's supervisor, and in a worse case scenario, law enforcement involvement. In my state, this falls under "interfering with public duties" and is an arrestable offense. However, I'm sure that the situation could be resolved LONG before the point of requiring LE involvement.

[VentMedic]

The lady had a history of skin cancer, which had been treated with at home chemo by pill. She was no longer doing the chemo. Also a history of high cholesterol and hypertension for which she took HCTZ and a cholesterol drug (I don't recall which one). No diabetes, cardiac history or heart problems. I looked at the nurses' paper work which indicated that it was a stage 2 ulcer. I am not sure what surgical intervention was required for the foot, but she wanted to go to the ER because she had a fever. Not for the foot. The home health nurses were there as part of her regular biweekly wound care.

I would say just take her. She probably won't live much longer to be a bother to the ambulance again anyway. Skin cancer can be very aggressive and like many cancer patients, they may put on a great front of denial. I've seen end stage breast CA patients try to do everything for themselves right up until the end. Or you could call the police. I'm sure what they will put her through wouldn't be any worse than what the cancer has put her through and will still put her through until the end.

In the time spent contemplating calling the cops, one could see if there was another truck in the area that could transport if you didn't want to go out of service for that length of time.

[firedoc5]

You said that you had to wait 35 mins. for the nurses to get done, plenty of time for a BLS transfer crew to get there. Or tell them you had to get back in service and to call back when they were done. Did the nurses or a doc order her to go? Or was it just her or her husband's idea? Either way, you just can't stand around waiting. If no one liked the fact that you had to be available for true emergencies, which this does not sound like one, than tough. But that's just me.

[crotchitymedic1986]

Just suck it up. Calling a supervisor is not going to change anything, you would have still had to transport based on her history alone. Anything you do besides transporting will most likely result in a complaint from someone. Were you abused, yes, but guess what, that happens. If you are a plumber, you have to deal with other people's feces. If you are a cop, you have to direct traffic in the rain. If you are a nurse, you have to wipe an ass from time to time. If you are a medic, you have to do non-emergency transports from time to time. She might not have needed ALS, but I would say the use of an ambulance was warranted. Since your service does not have a BLS option, then that means you should transport her (she does pay taxes, which pay for your service). Look at it this way:

For everyone else who is reading this: This was an opportunity to "touch" a life instead of "saving" a life. Why not let this taxpayor see a kind and compassionate EMS system, instead of an argumentative one ? This is one of those situations where you can choose to be NICE or choose to be right and piss everyone off.

[firedoc5]

Just suck it up. Calling a supervisor is not going to change anything, you would have still had to transport based on her history alone. Anything you do besides transporting will most likely result in a complaint from someone. Were you abused, yes, but guess what, that happens. If you are a plumber, you have to deal with other people's feces. If you are a cop, you have to direct traffic in the rain. If you are a nurse, you have to wipe an ass from time to time. If you are a medic, you have to do non-emergency transports from time to time. She might not have needed ALS, but I would say the use of an ambulance was warranted. Since your service does not have a BLS option, then that means you should transport her (she does pay taxes, which pay for your service). Look at it this way:

For everyone else who is reading this: This was an opportunity to "touch" a life instead of "saving" a life. Why not let this taxpayor see a kind and compassionate EMS system, instead of an argumentative one ? This is one of those situations where you can choose to be NICE or choose to be right and piss everyone off.

It's not a problem in making a BLS run. But if you are the last available unit for emergencies, then you have a responsiblity to be available for ALS. I think that's what the question was dealing with. Plus the wait time. During that wait time get another crew together and have them either take the BLS call or if they equipt for ALS , then have them respond to emergencies.