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Refusing to take a patient to the ER
I was on a run a few weeks ago where I had two other partners with me && we were called to a adolescent male who fell on the pavement, thus hitting his face/head onto the ground and creating a nice lac. on his chin which needed stitches. The parents called us and requested that we take him to our local ER && so which we prepared to do so as my partners bandaged his chin and we proceeded to walk outside with the child to the squad when my one of my partners says "Well, he looks okay for you (the parents) to take him to the hospital." The parents were a little shocked that he said that and they ended up taking him. When we got back to the firehouse I told my partner that I felt he was completely out of line in making that call and that he needed to go to the hospital, not just because he had a cut on his chin, but that he hit his head from slipping and falling onto the pavement. Idk if he was okay or not but we don't have the equipment or knowledge to rule out a head injury and so I shared how I felt with my partner (the one who made the call). Well, he didn't like the fact I told him how I felt, but I could really care less becasue my captain agreed with me and said he was the wrong one. But I was told by one of my admin. at my school where I attend medic classes that I have to report that kind of thing so that I don't get in trouble if something came up later down the road. Where do I go to do that?
Replies to This Discussion
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Permalink Reply by David on
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Hi,
Well this is a good question. I also instruct my students to report such behavior. I believe you made the right decision when you notified the Captain. You have gone through your "chain of command" and as such you have limited your liability. If you dont feel that the Capt. has taken the appropriate steps then you should go to the next step in the chain, wether that be the Deputy Chief or the like. This is not abandonment as the parents had agreed to take responsability for the child. But make sure that the documentation is there. IE: signed refusal and possibly contacting medical control if your protocols require that (they do in my system). You are right to be conserned about this behavior and hopefully your agency will take the appropriat steps to assure this does not continue. Of course there is always an agency that overseas EMS and they could be a point of contact if you feel this person is a danger. Usually though, the first step is to let the bosses know. You did good. Keep it up! be safe
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Permalink Reply by Spanner 122 on
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I guess erring on the side of caution is the right thing to do. I know here the pt is sometimes informed of the cost for a non-emergency run to the hospital. There are classifications of emergencies here and if you are asked for transport, you will pay for it. It's not cheap. A slip on the pavement and cut on the chin wouldn't even warrant a call to 911 in my books, I would have taken my own child to the emerg, as I have seen many others do for gashes to the head or face. I'm not agreeing or disagreeing, as I was not there, but I would have likely liked to be freed up for a real emergency and not left sitting at the hospital waiting for emerg to release me (and of course I say this as if it was truly non-emergency and deemed to be such).
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I guess I have to disagree here....a patient bill should NEVER be a reason not to transport. wether the patient has insurance or not the patient is your concern. let the billing company and the family deal with the issue of payment. The parents called 911 so unless they are the ones asking if they really need the ambulance, your job is to take the patient regardless of wether your assessment believes it to be warrented. Yes it does tie up an ambulance for a probable non-urgent transport. But we are not Dr.'s and we do not have the proper testing equipment to rule out a fx. lets not teach our up and coming EMT's the bad habits we have.
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Permalink Reply by ILDisasterEMT on
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Wow. There's a lot of grist for the mill here. Maybe a list would be the easiest way to go. Remember my perspective: I am first a foremost an EMT/Disaster Life Support Specialist who is training to run with a FD to run fire calls when needed but primarily for EMS/Medical/Trauma, MVCs, FF rehab, etc. I also happen to run my own business as a medical legal consultant where I work with attorneys who have cases which involved medical aspects trying to help them sort through all of the hundreds of pages of paper work. Im a paralegal and legal researcher specializing in just this kind of thing. Also spent 1 year in med school (before my own near death experience in a roll over/ejection accident) so my slant may be different. Bear with me here:
1. You went up the chain. Excellent. Not only is this protocol, it helps you document and have witnesses for your side if someone drags you into court. Dont rule out the possibility yet that you may get a notice to appear in a court case. People like to litigate and in my state there is a 4 year statute of limitations.
2. While David says this is not abandonment and I agree there is a fine legal hair to be split here, lets examine the chain of events and see what the legal requirements for a civil charge of abandonment are:
a. You had a duty to act. When you were toned out, your duty to act kicked in.
b. Did your patient have an existing and emergency condition which required medical attention? YUP!
c. Did you render care? Well...your crew did when you bandaged up the kids chin.
d. Did what you did or didnt do make the child's condition worse or cause further harm, injury and illness?
You really don't know.
3. We never talk a patient out of going. NEVER!!! Did I say never? That is the match that lights the fuse on abandonment.
4. Did patient's parents (assuming patient is a minor) sign a refusal? If so, was it based on information that there could be more wrong with their child than a simple chin lac.Even if they did, it could still come back to bite you partner in the arse because he essentially talked them into refusing T and T (treatment and transport) which as I say, we must NEVER do. Patient calls, you take them or treat them until transport gets there unless a refusal is signed in the mean time.
5. If a refusal exists, does it include that your partner talked the family out of being transported. If it doesnt, it bloody well should, other wise it just looks like they are refusing T and T of their own accord, which they clearly did not. We ALWAYS make every effort once we are on scene to get a patient to go. I have told patients "Look, you may feel icky now and not want to go, but I also suspect there may be something more serious wrong. Do you understand that if you do not go, you could die?" If they say "Yeah Yeah I get it" then your refusal, which is part of your PCR includes the fact that you advised the patient of all possible consequences which are up to and including death.
6. As an EMT/Basic Life Support Specialist (dont laugh, thats what my sleeve rocker says) I would like to ask your partner what on God's earth prevented him from assuming c-spine control and packaging this patient assuming possible c-spine/skull injury. ANY TIME A PATIENT FALLS AND REPORTS HITTING THEIR HEAD (which a chin lack indicates) THEY GET A COLLAR AND A BOARD AND THEY ARE GOING. end of story. That child could have lacked his chin which you saw when you got there. Then 10 minutes after you leave, he starts to get drowsy and nauseous. The his pupils are sluggish and unequal or worse F and D or he exhibits Dolls Eye. Then he goes altered. Then he seizes followed by LOC with no significant post-ictal recovery (ie status epilepticus). In addition the condition of your young patient which is always your primary concern, your partner has put your butt in a sling the size of Texas.
7. Document the hell out of this, including letters of what you saw, your educated opinion, concerns medically speaking, the attitude and reaction of your partner...everything you can think of. Take 24-36 hours to document so you make sure you don't leave anything out. Contact your medical control and your EMS director and see what they say and include this in your documentation. All of this should go in your after action report as well copied to your personnel file and to your partners with copies to Captain, Chief, DC, Medical Control and EMS director for your department. I dont know how long ago this happened, but get on top of it and ride it to its conclusion. Remember, even after it seems like its over and forgotten six months or a year or two years down the road, thats about the time the kids family talks to a lawyer or friend who says "hey this happened to me" and as long as its within the statute of limitations, your off to the races sitting in a court room being grilled by a prosecutor in your nice pressed uniform about why you did not take control. That being said, I dont think you did anything wrong. Its very difficult to "consult" with your partner in front of patients and concerned family. My advice: when he said that, i would have said to the parents "My partner and I want to confer for just one second, we will be right back" and then you tell your partner that he is not taking your arse down with his and you woud "appreciate it" if he would reconsider his assinine decision. There is also the reg that in most fire services and this is becoming more common as ICS permeates all aspects of the fire service, that you relieve your partner of his "command" or tell him to stand down and tell the parents to load the child into the rig becuse he has a potentially very bad injury. Also, I have been on situations where medics say "oh lets just let the family transport the patient" and the parents decide not to or the child goes to sleep and never wakes up. This is your patients life and your career. Again, you did nothing wrong, but that might not be the way the fire/rescue board or an after action review committee might see it.
Finally...personal experience. I was working a shift in the ER during my EMT academy. Call comes in that several hours post accident a family is transporting a 91 y/o female with a minor head lack because the medic on scene said it was ok, watch her, ice it, and take her if she feels dizzy. By the time the woman got to our trauma bay after being transported via POV, she had a widening pulse pressure, needed a ventilator, coded twice and eventually died after we worked on her in the ER and intensive care for 6 hours. Diagnosis: basilar skull fx with 9 cm paronchimal brain bleed. That FF/medic lost his job, his license and just about every penny of his welfare check goes to the family after a $10 million dollar judgement against him.
Sorry for the long post, but in emergency services, we cannot discuss this too much because the more we do, the better we get and the better we get, the better care our patients receive. I also want to end by saying that this is one reason why SOME people (not me) have a problem with fire based EMS. We simply cannot let this happen.
YMMV.
PS- just because your partner may have been your crew senior, that doesnt mean you dont go after misconduct/abandonment. All in all, I commend you for what you did, except that your partner should may have had an attitude adjustment with a halligan.
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haha... that's hilarious!!
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Hey, I'm just a firefighter, what do I know. I guess I just hear enough grumbling about wait times in hospitals for these non-emergency calls or so called "free rides" to the hospital. Here wait times can be in excess of 4 hours, because there are no beds and no nurses, if the pt is with an EMT, he is last on the list (unless critical). But, you're right, patient care should come first... you wouldn't believe what politics and disrespect between the emergency services dictates here. It's pathetic.
But, as mentioned, as the parent I wouldn't have called in the first place.
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Permalink Reply by Bob Bennett on
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First of all document it write it all down on what happened to C.Y.A. Then address your chief or your chian of command up on what happend. Suggest a meeting with all parties involved to disscuss the incident and come up with a solution on what to do if you run into this situation again.
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Permalink Reply by Joe Stoltz on
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We have an "Unusual Occurrence" form that we can use to document and report the incident. I have to agree that your partner was wrong, and the person should have been taken to the hospital with full spinal precautions. I had a teen who got hit in the head years ago, felt foolish and apologetic for strapping him onto a backboard with collar, but I later found out he had chipped a c-spine vertebra.
Having said this, I recall now refusing to transport a person to the hospital.
We had a "frequent flier" who lived with a family member, and would often complain of non-specific body pain. The patient would call 911, we would arrive, the relative would go ballistic when we showed up, we would transport anyways, and so on. The patient would be evaluated and discharged.
One time the call came in during an ice storm, and I ordered the ambulance to stay in the fire house. Roads were untreated and glare ice. Upon arrival at the residence I determined that it was business as usual and refused to take the pt. to the hospital. I said that I could not guarantee that the ambulance could get to the house, and even if it did I could not guarantee that we could get to the hospital safely. The large plow trucks were backing up the hills spreading salt, it was that bad.
I was EMS Captain at that time and it was my decision not to risk the lives and limbs of our members in transporting this person (complaining of the same symptoms as usual) to the hospital. I told this person that if symptoms had not abated in a few hours, to call us back and we'd be happy to oblige. We didn't get a call back - at least that day.
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Permalink Reply by Art "ChiefReason" Goodrich on
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Without a signed refusal from the parents or guardians, go luck with the lawsuit if you don't transport if requested to do so.
It seems like, after a while, the EMTs that I know, at least, start to cop an attitude and seem to have ALL of the right answers. Just ask them. They forget that they can only give to a certain level of care and will become a "doctor" in a momentary lapse. That becomes the problem.
Giving false hope is another favorite and another thread.
I would push your superiors to file a complaint. You need to be out of this ASAP.
Good luck.
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Permalink Reply by Mary Ellen Shea on
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funny....I worry about the future of America.
:)
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Seth-
You've missed the whole deal brother. The FF/EMT talked the parents out of transporting the patient to the hospital and from the sounds of it he did it because he didnt want to be bothered. That is a far cry from the parents just signing off on a refusal. And for the record, while a refusal form may be our field version of signing out AMA, they are also a far cry from being the same. Patients do not sign out AMA with us, primarily because they cannot because we cannot offer medical advice (AMA=Against Medical Advice). About all we can do is say "You know, if you dont go, you could become very ill" and under certain circumstances I have said "if you dont go to the hospital with us, there is a very good chance you could die." We dont give medial advice. All we do is convince the patient of the wisdom of going to the hospital in the strongest way we can.
As far as keeping quiet because you may f*&^ up yourself one day and not want anyone to say anything....thats a bunch of bull. God forbid I would ever be your command EMT and find out you knew the details of something like this and didnt tell me because I would kick you to the curb right along with the EMT who talked a patient out of T and T. Engage brain. Then open mouth.
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Permalink Reply by D.C. Sterbenz on
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You were absolutly right. If someone calls us out on a call no matter how severe the injury or illness unless they wish to decline transport. You should put in the report that you were against this that way if something comes of it your end is covered. I know it is not professional to disagree w/a partner or an officer especially in front of the public but you have a job to do. I assume that you are not an officer when you said that your captain agreed with you but the downside is this will ultimatly come back on him or her, it is his or her job to make the judgement call becouse he is ultimatly responsable for you and your partners actions.
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