Politely telling a patient "no"

[Fox800]

If I am dispatched to a evaluate a patient, I expect to access them ASAP for evaluation, assessment, and treatment. If the patient refuses to allow me to do this, then they are refusing treatment and I will return to service. If the patient wants me to do my job, and the home health care nurses are interfering, they will be removed from the scene. I have a job to do, and I am expected to provide competent care in a prompt manner.

[stcommodore]

transport to "closest apropriate" facility...

[crotchitymedic1986]

The day we start transporting only the patients who NEED an ambulance, will be the day you lose your job. Only 5-10% of 911 callers really need an ambulance, or should I say wouldnt survive a car ride to the hospital. Drop your call volume 60%, and lets see how many ambulances and jobs your county needs.

[spenac]

The day we start transporting only the patients who NEED an ambulance, will be the day you lose your job. Only 5-10% of 911 callers really need an ambulance, or should I say wouldnt survive a car ride to the hospital. Drop your call volume 60%, and lets see how many ambulances and jobs your county needs.

I say that would be a wonderful day to get back to people taking care of themselves except when it is a real emergency. Fine if some jobs are lost at least those left would actually be doing something besides being taxi drivers. But also honestly would not really impact revenue for the service as those BS callers insurance will not pay if they have it and the patient will not pay so actually the service would have more money because it would not be loosing so much on wasted taxi rides.

[crotchitymedic1986]

Tell that to all the fire departments that educated and coded themselves out of jobs.

[pond life]

I only know the US system slightly from ridealongs in Seattle area but if this were in the UK I would approach this slightly differently.

This is a holistic call in which you are meeting not only the clinical needs of the patient but the social psychological needs of the family and possibly even the nurses.

I would ask the nurses if they believe the patient has deteriorated in their opinion.

I would ask the husband and any other relatives what they would like to see achieved here. Noting that certainly one option is to take to the ER however there are other options available - ie treating in the community or admission to a community hospital.

When the husband comes back with 'the ER please' I would be taking him to one side and asking if he is finding it more difficult to cope at home with his wife's failing health are there any other issues here and if there's anything I have not been informed about (possible facing up to spouses deathe etc).

If I could gain the trust and co-operation of the nurses and relatives alike I could then begin base line obs including temperature, urine dip test and other assessments to identify the source of the pyrexia. It may be that the patients immune system is low and has chest infection or pneumonia - in which case I would assess CURB65.

At the end of the day if there are no red flags I would opt for a treat and refer for the patient (rather than treat and release). If appropriate after my assessment I would take to ER but may also consider alternatives such as BLS transport to a ward in a community hospital or I may prescribe Pen V if appropriate with a follow-up with an acute care at home team.

If I went down the road of non-conveyance I would sit down with the patient and be specific of why the patient is not going to ER but will ensure a good safety net is in place.

Mike Bjarkoy

Paramedic/Emergency Care Practitioner

Penzance. Cornwall. England

[CTXMEDIC]

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.

he works for a hospital based system, taxes are a non factor. they called 911 for a fever, whatever. they didnt want to go when you arrived, its time to leave and tell them to call back when theyre ready to go. supply a NON emergency number to your service. tell them they can schedule an appointment for pickup if she needs to go out of town. tell her that her insurance will NOT cover the ambulance ride to a facility an hour away when there is a CLOSER APPROPRIATE FACILITY that can deal with her 'fever'. she was in no distress and she had NO complaints. her husband called and she said shes fine, sounds like a refusal to me. and yes, a supervisor CAN change things. my service would try and talk her into a wheelchair van at best or send a BLS truck so a basic can stare at her ulcer for an hour.

[VentMedic]

he works for a hospital based system, taxes are a non factor. they called 911 for a fever, whatever. they didnt want to go when you arrived, its time to leave and tell them to call back when theyre ready to go. supply a NON emergency number to your service. tell them they can schedule an appointment for pickup if she needs to go out of town. tell her that her insurance will NOT cover the ambulance ride to a facility an hour away when there is a CLOSER APPROPRIATE FACILITY that can deal with her 'fever'. she was in no distress and she had NO complaints. her husband called and she said shes fine, sounds like a refusal to me. and yes, a supervisor CAN change things. my service would try and talk her into a wheelchair van at best or send a BLS truck so a basic can stare at her ulcer for an hour.

You're right. Cancer that requires a wound vac is nothing to complain about. She should just tell her husband to shut up and die already. Geez, imagine an immunosuppressed patient's family worrying about a little fever. It is such a bitch to get sick and be a bother to the EMTs. And heaven forbid you do need a specialist in this country. Like I said before, anyone that gets sick should never be stuck in the boonies if they are sick where there is only one ambulance and probably not even a taxi.

This is where helicopters get sent to calls that should have been handled by ground ambulances. Some one blows off a patient to where it becomes an emergency or the ground ambulance doesn't drive very far and then get stuck at a little general. A helicopter must then be dispatched to the tune of $10K - $15K instead of $1500.

Like I said before, only if you and your area have a working reasonable alternative to get a patient with special needs to the appropriate facility, you should rethink your argument. Just refusing or taking to the nearest facility and dumping is not the answer. Your system needs to be reworked. The patients shouldn't suffer because there are no reasonable alternatives.

[CTXMEDIC]

You're right. Cancer that requires a wound vac is nothing to complain about. She should just tell her husband to shut up and die already. Geez, imagine an immunosuppressed patient's family worrying about a little fever. It is such a bitch to get sick and be a bother to the EMTs. And heaven forbid you do need a specialist in this country. Like I said before, anyone that gets sick should never be stuck in the boonies if they are sick where there is only one ambulance and probably not even a taxi.

This is where helicopters get sent to calls that should have been handled by ground ambulances. Some one blows off a patient to where it becomes an emergency or the ground ambulance doesn't drive very far and then get stuck at a little general. A helicopter must then be dispatched to the tune of $10K - $15K instead of $1500.

Like I said before, only if you and your area have a working reasonable alternative to get a patient with special needs to the appropriate facility, you should rethink your argument. Just refusing or taking to the nearest facility and dumping is not the answer. Your system needs to be reworked. The patients shouldn't suffer because there are no reasonable alternatives.

youre right. i should send my last als unit in the county on a bogus, no pay transfer an hour away. I have NO problem driving a million miles for a transfer. Last summer i drove 7 hours ONE WAY to take a patient back home to bury her husband that she was in an MVC with. This patient actually required stretcher transport though, unlike this guys wound vac lady with NO COMPLAINTS. was she sick, probally, thats not in dispute. at least with me it isnt. my problem is that im passing up an APPROPRIATE FACILITY that can deal with her fever. if for whatever reason the little hospital can NOT deal with it THEN they transfer her to a higher level of care and THAT is actually going to get covered instead of sticking gramma with a $700 bill and shafting the other residents of the county by taking my last ALS rig out of service for 2 hours. you are absolutley correct that REFUSING to treat and or transport is not an option. taking her to a hospital an hour away when there is one 5 minutes away is an option. if this patient actually needs to or wants to go to her preferred hospital then we can shuffle trucks or even refer her to a private service for transport. By contract, agreement, whatever, this guy has to respond to 911 calls in his service area and transport those patients to the most appropriate facility. taking grannys infection to a hospital 5 minutes away isnt going to make her 'suffer'.

[spenac]

Patient as presented does not need an ambulance. Sorry Vent. It is not me being lazy.

Thats say I get to this patient. I will do a full exam, wait no the nurses will not move. Well if you dial 911 she became my patient, so move. Still not move I ask patient do you want me to examine to see what we can do for you. No, or no not right now. Good bye we're back in service. Or if yes please. Move over nurse you heard the patient. Ok let me see, get complete HX, complete exam. So while you have major health problems those are not the concern tonight. Thats right you handsome young man. OK then with your only complaint and based on examination everything is basically normal for you I will have to recommend we assist you to the car for your husband to take you to the doctor. Ok thank you young man. Or for worse case I demand you take me. Sorry ma'am I have to advise you your not in an emergent state and we transport only emergent patients. If you would like we can assist you into your car. But you have to take me I am sick. Yes ma'am you need to see a doctor but do not require an ambulance, again please allow us to help you load into the car. At this point either we assist her into the car or we bid farewell and leave.

Yes I am a handsome young man before you all jump on that. :roll:

I will be polite, compassionate, professional but I will not be a taxi driver. If during the exam despite her complaint I discover something that indicates sepsis or other yes I will load her up. If I loaded just for the fever no way she goes anywhere but closest hospital. If upon exam again I find things that indicate she is actually suffering complications that would benefit from quicker access I would see if there was a way for mutual aid to come in and I would take her. You know I just can't resist someone calling me a handsome young man. :wink:

OK ramble over for now.