Thought provoking article in JEMS re: Patient refusals

[mediccjh]

2.75

[mommaparamedic]

Our job is to take anyone anytime to the hospital when 911 is called...if you dont want to do your job...then GET THE HELL OUT......the remark stated above is not acceptable....shows 2 things 1. no compassion. and last but not least POOR PROFRESSIONALISM..... even the bs calls the patient needs to be treated with respect and dignity...to you it maybe bs to them it may be serious.....it is like always in the preception.......

[bullmedic]

We have initiated two distinct and different policies. The first is a Paramedic Refferal Program and the second is a Paramedic Inititiated Refferal. The first can be done by all of our medics. It is a mechanism that allows us to contact medical control and refer the patient to a facility other than the ED. This may be their PCP, an after hours clinic, or a non-emergent or semi-emergent clinic. The medic simply asseses the patient and contacts medical control. The med control physician either agrees with the paramedics assesment or doesn't. If he agrees we leave the patient with directions to follow-up with the appropriate level of care. All of these reports go through our QI process and each medic is responsible for his decisions. If a question arises and the program has been used inappropriately that individual is no lponger able to use the program. The second level is the Paramedic Initiated Refferal. This is reserved for our street managers. We have 4 assigned per shift. There are generally 3 working on units and 1 roving in a supervisory capacity. These individuals can, without med control, tell an individual that we will not be transporting them for a very specific group of complaints. They are:

#1 "Patient's without complaint or mechanism of injury." (These could be the "I am out of my pain meds" patients or somone who just wants to be checked out (i.e. BP check, Glucose check)

#2 "Animal Bite" Obviously this is left to the discretion of the Unit Commander involved. If someone was attacked by a dog and has serious injuries we will transport. If someone has a minor bite to an extremity with controlled bleeding they certainly fit.

#3 "Lice infestation" Again obviously not an emergency situation. Most reasonable people would not call an ambulance for this but folks here have done so and will continue to do so.

#4 "Foreign object in ear/nose" Again our unit commanders make the call here.

#5 Minor bruise, laceration, abrasion. Non-specific extremity pain/minor swelling due to trauma."

#7 Sutures

#8 Isolated toothache

If you have any questions I would be happy to answer them.

[Ridryder 911]

Yep, the old days of "You call, we haul" are over. That is what taxis are for. If the patient needs medical attention then we should provide such, but to charge people $800 for a taxi ride without need of care is not right for the patient or the system.

R/R 911

[Guest DELETED]

DELETED

[whit72]

If you work in a system where your medics and emts get to decide who goes and who dosent go to a hospital there is a problem. If they activate the system they go. There is no well maybe go to your doctor or maybe go to the bathroom. Gimme a break. If they are not emergent you can park them in triage. The liability with leaving someone on scene is outrageous it dosent take that long to trans. someone to the hospital. Who are we to decide what is and what isnt and emergency for some people, there taxes pay your salary. I have taken people that are lonely, hungry, scared, if they want to go they go. Remember those famous words "I just dont feel right" let me guess you leave them to. If they activate the system and dont want to go then you have to contact medical control for further instructions. If they dont want to go, you can only hope to convince them, you dont have the right to remove people from a scene if they refuse to go. unless their altered thats is the only way we can take someone against their will.

[SSG G-man]

We do not refuse to take anyone who wants to go. Also, sometimes the patient is not the person who "activated the system." A passerby calls in an MVA. Driver could be fine and would have been on his way after dealing with the Police if we had not received a call. We document fully any time patient refuses treatment or transport. Patient refusals are not a refusal to transport. I see them as to separate issues.

Sarge

[Nate]

If you work in a system where your medics and emts get to decide who goes and who dosent go to a hospital there is a problem. If they activate the system they go. There is no well maybe go to your doctor or maybe go to the bathroom. Gimme a break. If they are not emergent you can park them in triage. The liability with leaving someone on scene is outrageous it dosent take that long to trans. someone to the hospital. Who are we to decide what is and what isnt and emergency for some people, there taxes pay your salary. I have taken people that are lonely, hungry, scared, if they want to go they go. Remember those famous words "I just dont feel right" let me guess you leave them to. If they activate the system and dont want to go then you have to contact medical control for further instructions. If they dont want to go, you can only hope to convince them, you dont have the right to remove people from a scene if they refuse to go. unless their altered thats is the only way we can take someone against their will.

:roll: And we wonder why EMS isn't seen as a profession. Believe it or not, we don't need a doctor to hold our hands every step of the way. Wait, you might need a doctor to hold your hand every step of the way. Most (paramedics and EMT's) are actually capable of thinking through a patient assessment. If you run every little thing to the ER and don't allow for refusals to be offered to the patient (who doesn't want to go or doesn't need to go), then you run the risk of opening yourself up even greater costs due to lawsuits (not having enough ambulances) or belly up (not being able to pay for all of the ambulances).

[Ridryder 911]

Apparently Nate, they do not work in a busy system. It does not take a rocket scientist to examine a "toe pain for 6 months" these type of calls, do not require EMS transport. Not only is it abuse to the system, but you are not being a patient advocate as well. Sorry, unless they are medicare or medicaid, they do not pay any or part of my salary. Even then if they are Medicare or Medicaid only up to 80% of the EMS call are paid by them (if it is justifiable and warranted).

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.

Be safe,

R/r 911

[Arachne]

I've always wished that "when to call 911" was part of the health classes or "life skills" classes that are taught in middle and high schools. They taught me how to put a condom on a cucumber, and that alcohol and sex are bad, but they manage to leave out a lot of more useful things, like when to call 911, when to call your primary care doctor, why you should read the directions on OTC drugs, and all those things. (Not to heap more responsibility on schools, but if they're going to take the time to teach health class, why not include more than sex, drugs and alcohol?)

The article mentioned this case: "In a Michigan case, EMS responded for a patient who had suffered an acute stroke.(3) The patient's wife requested transport to Spectrum Health in Grand Rapids, but EMS took him to Mecosta County General Hospital instead. After a CT scan, the hospital determined that the stroke was caused by an embolus, but failed to administer thrombolytics and failed to transfer the patient quickly to another hospital. The patient finally arrived at Spectrum after the three-hour window for administration of thrombolytics had elapsed, and he sued for "loss of chance," alleging that the failure of EMS to take him to Spectrum as requested caused him to lose the chance of recovery he might have had if the thrombolytics had been administered. He suffered paralysis and severe neurological damage from the stroke."

It would be interesting to know if the lawsuit was only against EMS, or if they also sued the receiving hospital. It seems to me as if the hospital is to blame for delaying appropriate care as well (and would probably be a more lucrative target for the family).