No Transport

In my state, “treat and release” is not in the paramedic scope of practice. While we regularly “treat and release,” this occurs only through the refusal process, after first offering/advising transport X 3 to the patient.

This morning I responded to a dispatch for “altered mental status” and on arrival, found a babbling middle-aged woman sitting on the toilet playing with her underwear. The first responders offered to get our stretcher for us (which we had left in the ambulance due to the pouring rain). Seeing my glucometer reading popping up at 34 after doing a finger stick, I told the responders to wait to see if we would be transporting or not.

An amp of D50 later, the woman was apologizing for bothering us, and refusing our advice of transport to the hospital. She forgot to eat last night, she said, after having spent the previous day hiking. She said she was back to normal now and did not want to go to the hospital. She promised to check her sugar regularly, and to follow up with her doctor. Her boyfriend was already cooking her toast, eggs and bacon. They both assured us they would call us back if there was any change in her condition.

Still we made the dutiful effort of offering transport X 3 before accepting her refusal, witnessed by her boyfriend and the police officer.

In the last week, these are some of the refusals I have taken:

A woman who called 911 because she thought the medicine the ED had just given her for her nausea was an “antipsychotic” instead of an “antiemetic.” Somehow she had looked Prochloroperazine up on the internet and had determined it was the same as Thorazine, which quite upset her. Once I showed her prochloroperazine was, in fact, compazine, she said “never mind.”

A woman whose lengthy oxygen cannula was tangled around her so badly that she could not walk without fear of tripping. She wasn’t hurt, she just wanted to be untangled.

And two calls at the jail to check prisoners for scratches received during the altercations that led to their arrests.

On each of these calls, I dutifully offered transport at least three times. Each patient refused. I collected their signatures on the dotted line and thoroughly documented each encounter.

I feel rather silly sometims advising people to be seen at the ED when I didn’t think they need to go.

Perhaps there is no more uncomfortable area for recommending transports than when we are called for the “prisoner evaluation.” Aside from the scratches and bruises from fights, we often get called to the local jail on a Friday evening of a holiday weekend to evaluate a prisoner who says he is not feeling well — a classic case of “jailitis.” Again, while we are called to the jail for an “evaluation,” since treat and release is not in our scope of practice, we have to evaluate and then recommend transport. Law enforcement, of course, often believes the patient is faking and they have no intention of sending the prisoner with the required officer/chaperone to the hospital. The cops look to us to tell them the patient is fine. They are covering themselves by passing the liability to us. We have a fine line to walk in dealing with these patients – hold true to our medical policies while not jamming up the police department unneccessarily.

Let me be clear, I am not talking about the prisoners who I believe actually do need to go to the hospital, and who I will fight vigorously to see get the care they need. I’m speaking of the malingerers.

Now certainly there is something called the art of the refusal. There is a way that your advice is prefaced and phrased that varies to the degree of the urgency of the patient.

I did not speak to the woman who had mistaken compazine for Thorazine in the same way that I would address a man with crushing chest pain and an ST elevation who is refusing to go to the hospital. Nor do I address the prisoner punched in the face without loss of consciousness or complaint in the same way I speak to the man who made a face impression in the windshield of his car at 55 miles an hour. Tone and body language certainly come into play. If they need to go, I am quite earnest and animated about it. If not, I simply cover the legal bases.

“If you are not transported, you might die.”

versus

“You were punched in the face. There is nothing I can do to have you unpunched. I don’t feel any broken bones. You did not lose conciousness. Your vitals are normal. You appear to have a completely intact and normal nuerological function. I am however, legally required (3 times!) to advise and offer you treatment and transport to the hospital. I cannot however take you against your will. If you do not wish to go, sign here (hand them pen and point to signature line), but you can always change your mind and call us back five minutes from now, an hour from now or whenever you feel there is a change in your condition, and we will be happy to return and take you to the hospital. It is your choice. (Again hand pen to patient if they have not already taken it).”

I write this because of the swine flu. I am hearing that some states are instituting measures whereby if an EMS crew arrives at a scene and finds an otherwise healthy person at home, feeling yucky with a fever and vomiting, the paramedic or EMT would call a medical hotline and speak with a nurse who, if she believes the patient merely has the flu, might tell the patient to stay hydrated and stay at home, and EMS would clear.

Should such a measure be implemented in our state, it would mark a change in the way we do business — a welcome change in my opinion. Maybe such an experience with the swine flu could lead to a general purpose hotline with either a nurse or physician on the end of the line who could make some of these transport/no-transport necessary decisions, so we don’t have to go through the recommend X 3 charade we do everyday. (Like some of my fellow bloggers lately, I do not advocate EMS making these decisions without at the minimum, a medical control consult.)

A problem with the nontransports is the ambulance companies don’t get paid if they don’t transport. Creating a reimbursement mechanism certainly involves a lot of work at a lot of levels.

Maybe the President’s Health Reform can focus on this. I’m an optimist.

***

As an FYI, attached is our state’s new policy on how EMS should deal with the many situations that arise when called to a jail or detention center:

EMS RESPONSE TO DETENTION/HOLDING FACILITIES

EMS providers are often called to detention or holding facilities to assess, treat and transport
detainees. It is important to keep in mind that detainees have the same rights to medical treatment as does the lay public.

Request for Evaluation Only

While it is beyond the practice for paramedics or EMTs to provide intentional treat and release
services, EMS responders often encounter situations where a patient (or law enforcement) desires evaluation, but does not want transportation. When in such a situation, EMS responders must treat the scenario the same as they would a patient in a home or at an accident scene who requests evaluation only. The EMS responder should follow good medical judgment in these situations, including doing a full history and assessment. Vitals signs should be assessed, including checking blood sugar if relevant.

Patient/detainee Refusal of Transport

If in the judgment of the EMS provider the patient/detainee should be medically evaluated at the hospital, every attempt should be made to convince the patient/detainee (and law enforcement) to allow ambulance transportation to a local medical facility. EMS responders should offer transportation several times; fully explain the potential medical consequences of refusing care to the patient/detainee and make every effort to ensure all parties understand the risks, and advise the patient/de
ta
inee to ask the law enforcement officer to recall 911
if necessary. Should the patient/detainee refuse this offer of transport, a full refusal PCR should be completed. The law officer should witness it. In the event the patient/detainee refuses care and refuses to sign the PCR, document this fact and have the law officer attest to the patient’s refusal to sign.

Police Officer Ordered Transport

In the event the patient/detainee refuses treatment and transportation, but law enforcement orders it, EMS should transport the patient/detainee and document all circumstances in the PCR. In all cases a law enforcement officer should accompany a detainee in the ambulance.

Law Enforcement Refused Transport

In the event the patient/detainee requests transport, but the law enforcement officer refuses to allow the patient/detainee to be transported, document this fact, including the name of the officer in your report. The officer can legally sign a refusal for a patient/detainee who requests transportation (however in practice this is not done – normally the patient/detainee will sign). Documentation should also include the EMS responder’s cautions to the law enforcement officer on the consequences of withholding necessary evaluation and or treatment. The EMS responder should request that the law enforcement officer sign under this documentation. Medical Direction must be contacted (see section below).

Medical Control

EMS responders are always encouraged to contact Medical Direction to allow the on-line physician to speak directly with the patient/detainee or law enforcement officer in an effort to convince them of the need for further medical evaluation. In all circumstances in which a patient/detainee is given an approved EMS medication such as a breathing treatment or dextrose, and then refuses transport or has transport denied by the law enforcement officer, the EMS responder must contact Medical Direction.

Scope of Practice

At no time should an EMS responder perform any treatments or evaluation methods beyond their scope of practice such as administering insulin, dispensing or verifying medications.

Transport Destination

The law enforcement officer may determine the hospital of choice unless it conflicts with
patient/detainee need as determined by regional guideline or state regulation. Medical Direction should be contacted with any questions.

7 Comments

  • On The Road says:

    Perhaps if you and your colleagues started using the same level of encouragement to all – working to rule, and persuading as many as possible to go to the ER, whilst causing mayhem in the short-term, it may encourage management to think about how they could do something about it, perhaps allowing paramedic initiated refusals, with or without medical command intervention.

  • Medic(three) says:

    our guidelines(we don't have protocols, just "guidelines") allow us to "no ambulance needed" a patient. If there really was no need for us to come, we can do a no signature, no name report. I have 2-3 a shift during my nights. For PRS we have standard PRS, and PRS Treat and Release–accept treatment, refuse transport.

    I can't imagine having to get signatures on some of the "no ambulance needed" calls I have.

  • TOTWTYTR says:

    A woman whose lengthy oxygen cannula was tangled around her so badly that she could not walk without fear of tripping. She wasn't hurt, she just wanted to be untangled.

    We responded to a "Difficulty Breathing" call for a nice lady whose cat had chewed through the tubing on her cannula. We replaced the cannula and she was back in business. No reason for ALS to go, since it was pretty clear from the comments on the call what had happened.

    Police station calls are a pain in the posterior. It's a game between the prisoners and the police. The prisoners want to go to the hospital because the beds are more comfortable and the food is better. Plus, they think that there's a chance to escape in many cases.

    The cops don't want the prisoner to go because they have to assign a 2 man unit to watch them.

    Guess who's in the middle?

  • Anonymous says:

    So youre a paramedic but you can't say someone doesn't need hospital? In the uk, any practitioner (technician, paramedic, nurse/para ECP) can leave a patient at home that doesn't need it. In my jurisdiction they can also bypass the ER and refer, either stand alone via the medics or with the patients or out of hours gp, to a medical addmisions ward or other health care provider. This is all without 'medical cobtrol'. Seems you work in a system so frightned of litigation it won't let you do your job, which is a great shame.

  • P says:

    Thanks for the comments. The US, and then my state, in particular, the legal system and regulations guide much of what we can and can't do.

    We do have a category I didn't mention which is no injury. If I am called out to a motor vehicle and the police officer tells me there are no injuries, I can clear no patient. But again this is subject to some interpretation. I remember years ago we were called to a minor motor vehicle accident that incolved a 16 year old driver and his 16 year old passengers, and they were not hurt and had not called. Because they were minors, our supervisor said we had to stay with them until their parents came, which tied us up for an hour and they were not even hurt. Today, I might clear that call no injury, no patient, but with the nagging fear I could be sued and lose my license for abandonment.

    Whether you work commercial or municipal can also influence how you are encouraged to handle calls. A commercial service might emphasize transport to the hospital where a municipal service might encourage you to call a patient's doctor, and do some extended social work, arranging rides to a walk-in etc. You still would need to advise transport X 3 and secure a signature refusing transport. I have done this on occasion working both commercial and municipal, but for liability reasons, it is probably frowned on.

  • fiznat says:

    Prehospital Emergency Care recently published a new article about this concept. It seems that Parmamedics pretty consistently mistake critical and non-critical patients about 10% of the time. Take a look when you get a chance:

    Prospective Evaluation of an Emergency Medical Services-Administered Alternative Transport Protocol, Prehospital Emergency Care, Volume 13, Issue 4 2009 , pages 432 – 436

    Here is the abstract:
    http://www.informaworld.com/smpp/content~db=all~content=a914291834

  • ben says:

    I have worked in London and New Zealand and both EMS services allow assess/treat and release. I can not comprehend a system that expects you to decide what drugs to administer, when to cardiovert, intubate, identify and decompress a tension pnemothorax, etc… but deems you incompetent to decide if little Johnny needs to go to hospital or not for that scratch to his knee.
    And don't tell me that a nurse at the end of a phone can accurately assess anyone any better.
    In regard to the recent research stating that EMS services sometimes get it wrong, then we should be increasing training to decrease these occurances.
    Also remember that nurses, doctors and whole hospitals get it wrong sometimes, so please put it in perspective.

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