I have the distinct memory some eons ago of working as a newly promoted captain/paramedic and going on a call at which the ambulance crew was already on the scene. When I arrived, I walked into a home where two paramedics were already treating a patient in the front room. As I walked into the room, the female patient was sitting in a chair facing me and the paramedics had their backs to me. They did not see me come in and did not realize I was there. I could see they had brought all their equipment in, had the woman hooked up to get an EKG reading and apparently had already taken a blood pressure since the blood pressure cuff was on the patient’s arm. The paramedics were asking her what was wrong and getting a history.
Apparently, the woman was suffering from some type of gastrointestinal problem and did not appear to be in any type of severe distress. She appeared to be in her late 40s or early 50s. As I listened to the paramedics go through their final assessment question, the one paramedic said, “I don’t think you need to go to the hospital” and “Everything looks fine.”
My immediate thought was, What? How do you know what is wrong and she does not need to go to the hospital? Did you draw blood and have it analyzed? Did you get an x-ray of the stomach? I never even saw you palpate the stomach!
Dangerous precedent
Making a diagnosis on scene and telling a patient nothing is wrong is like playing Russian roulette. You may get away with it several times, but eventually you are going to tell the wrong patient that nothing is wrong, have the person sign a patient refusal and then come back several hours later or the next day to find him or her dead. Talking a patient out of going to the hospital sets a dangerous precedent.
Some non-patient transports that have hit the news in the past few years include the non-transport of a 2-year-old girl in Washington, DC, who was suffering from a cough and congestion. The paramedic crew told the mother to put the girl in the shower and run hot water to clear up the congestion. Less than 24 hours later, the mother called again because the child’s condition continued to deteriorate. The girl was suffering from pneumonia and died from her condition.
Another incident that made headlines in Washington, DC, occurred in 2008, when paramedic crews responded to a man complaining of chest pain and the crew told him to take Pepto-Bismol since he was suffering from acid reflux. The man died some hours later after the crew persuaded him to sign a refusal form.
If you really want to put your career into a precarious position, make it a common practice of diagnosing patients in the field and telling them nothing is wrong with them. And just because you get them to sign a patient refusal, don’t think you are legally covered. Just because you have a signed refusal does not mean you are in the clear. You can still be sued and attorneys will go after you for not doing a complete assessment, missing some sign or symptom, not taking a vital sign, not following your protocols or something else you may have missed. You should make it a common practice that regardless of the chief complaint, any child under age 9 and any adult over age 65 should automatically be taken to a hospital.
A study published in the Annals of Emergency Medicine in 2002 called “An Analysis of Out-Of-Hospital Refusals of Care” showed that as many as 3% of all patients who refuse care will call 911 again within one week of their initial refusal. Among these patients, children under 3 years old and adults over age 64 are admitted to the hospital more frequently than other age groups. Seventy percent of patients 65 years of age and older who initially refuse care required some form of follow-up care, according to the study.
Quality documentation
If you are going to get a refusal from a patient, it is imperative that you have proper documentation. In my consulting work, I read many patient care reports from around the country. Many times, I am appalled at what paramedics write in these reports. I like to tell paramedics to write documentation as if they are painting a picture for someone who is not at the scene, but will read the report two years from now.
In some cases, the decision of whether to transport a patient is not left to the paramedic. The medical director in the Memphis, TN, Fire Department has a protocol called a “mini-mental exam” – if the patient cannot achieve a specific score, he or she is mandated to be transported to a hospital.
Not transporting patients to a hospital is a serious and dangerous event. As I tell my paramedics, it takes only one call to put you on the front page of the newspaper or in a courtroom because you are being sued for negligence and deviating from what should be the standard of care.
Gary Ludwig will present “Management Case Studies for EMS Managers” and “Does the EMS Manager Know About This?” at EMS World Expo 2012, Oct. 29-Nov. 2 in New Orleans, LA.
