The joys of living in a small town........had a patient who was found on the floor of his apartment, barely responding, unable to stand or sit up, unable to answer what day it was, eyes rolling back in head, apnea, in and out of consciousness. The patient lives alone with no family or caregivers available to stay in the home with him. Patient is end stage cirrhosis of liver. Phoned ambulance service for non-emergent transport to hospital. Paramedic comes in (happens to own the ambulance service, as well) and asks patient if he wants to go to the hospital. Patient can barely arouse but says 'no'. Paramedic says "call off the run, we can't take a patient if they say no." WHAT THE......??????? I got a little ticked (understatement) and said "He's barely conscious, he has fallen, he cannot adequately answer questions, and you think he's coherent enough to make that decision on his own????" Paramedic got a little ticked (understatement) and began to lecture about how it's false imprisonment to force a patient to go to the hospital, and I really need to calm down here......That's when I REALLY lost it (not proud of that, but it happened) and said "I wouldn't have called you if I hadn't needed you. He is not capable of making a sound decision at this point in time. We need to get him to a safe place." Paramedic then tells me "It's MY ambulance (it is, really) and I get to say who gets to ride in it. You can't tell me what to do." I looked at him and said "Well, walk out and I WILL report you for abandoning the patient." Then it got a whole lot uglier from there verbally.
Eventually I called in another nurse because I knew I had lost control of the situation and was not coherent myself . She smoothed it out and patient was transported. Turns out he had overdosed on medications. I found out later there is a law in my state that says if a patient is incoherent, they are incapacitated and MUST be transported to a higher lever of care. I AM FURIOUS. Was I wrong? And should I just let this go or complain officially? Any advice appreciated.
I don't know what state you are in, but in my state, all EMS agencies (including critical care transports) are required to get medical advice (usually from the ER docs where the patient would be transported) on the acceptance of a refusal of transport. If this paramedic made the decision without contact for physician approval, he could lose his certification in the state I live in.
It's not this way in Texas. We just chart the refusal, sometimes without even getting ID-- back when I was active EMS we'd show up at MVCs where everyone was superficially fine and everyone rejected EMS treatment and transfer on a daily basis.
I don't know what state you are in, but in my state, all EMS agencies (including critical care transports) are required to get medical advice (usually from the ER docs where the patient would be transported) on the acceptance of a refusal of transport. If this paramedic made the decision without contact for physician approval, he could lose his certification in the state I live in.
Not the case here in KY... what's the ER doc going to do come to the scene and force the patient to be treated? However we usually err on the side of the patient and encourage transport, sometimes staying on scene for a while trying to convince the patient that medical treatment is needed. I can't speak for the medic in question here, but I would rather transport someone who is going to be treated and released in the ER than not transport someone who is going to go bad if left to their own devices. We are legally resposible for our actions as EMTs and Medics. I can be sued just as quickly as an EMT as I can as an RN.
Theres a difference between a "stupid decision" that is based out of pure stupidity and ignorance, and a patient having a medical issue, clouding better judgement.
If the patient is not of sound mind, they cant refuse treatment. If they refused, and we as healthcare providers said, fine, we wont do anything for you, and miraculously they get better, and come to realize they had poor judgment, but couldnt help it due to the medical issue and were harmed maybe in some way along the process because we didnt do everything in our power to help them when they werent of sound mind, dont you think our rear ends would be sued?? Im sure we would not be able to argue the fact that the confused patient "refused".
My post was in reply to a post about the ethical nature of watching people make poor decisions when we have the capacity to treat, not the scenario presented in the OP.
I wasn't there to say whether or not the patient was capable of making such a decision.
I think hypocaffeinemia (great name!) covered the basics already.
I would like to reemphasize that any patient who presents as in the original post is an EMERGENT patient until treated or proven otherwise. If D50 or Narcan straighten it out on scene (if appropriate, of course), then the medic (who should still transport IMO) has to deal with a possible patient refusal. As long as there is altered LOC of unknown origin, I'd bet there isn't an EMS medical director anywhere who would say this isn't emergent.
Any EMS crew finding the presentation in the OP would be clearly obligated to treat or transport or wait on scene/intercept for an ALS crew if need be. Doing nothing wouldn't be an option.
Any visiting nurse finding such a patient should be calling 911. Altered LOC is an emergency until treated or proven otherwise. That will only get defined in the ER.
If the facts are really as you presented, this needs to be addressed. Your boss should be contacting the medical director of the ambulance service and requesting a professional sit-down to review the incident.
If it really happened that way, that's appalling and worse.
Medic09, while I agree with you, I'm confused as to why a non-emergent transfer service was called nistead of 911. This part of the story doesn't make sense to me- he can't be falling and too disoriented to give proper consent, while simultaneously only requiring non-emergent transfer.
While the paramedic's actions as described need to be addressed, so does this aspect as well.
It's interesting that the laws and regulations of EMS refusals of care differ so greatly between states (and between different providers).
One local EMS service doesn't do transfers at all. So, if they encounter a stable patient at a LTC they can refuse to tranfer the patient to the hospital after assessing the patient, since for certain things it's considered a transfer instead of a transport. Apparently it has something to do with a LTC meeting the requirement of being a medical facilty where care is being provided. I've never understood this delay in moving the patient though, especially if the doctor for the patient is ordering the transport. However, I've never heard of them refusing to transport any patient that needed immediate care. I've also known them to stay on scene until another EMS service that does do transfers arrives.
Even if all of this is legally ok, it still frustrates me, since it's the patient who gets the raw end of the deal.
Specializes in Community Health, Med-Surg, Home Health.
I would probably report it as well for several reasons...one being a teaching or rather a receiving of education for myself. I need to know what is legal and what is not, and how it is to be handled for future reference. I am famous for writing down names, dates and responses and also, keeping communications on said situations on file for 'just in case'...
Also, I do believe that until a person has been properly diagnosed, you cannot say for sure what the reason for their response is. A lack of oxygen would make a person more confused, more unable to make their own decisions, so, as a nurse, I would want that person transported. I see nothing wrong with a few cuss words out of frustration, so, you get on arguement from me.
Medic09, while I agree with you, I'm confused as to why a non-emergent transfer service was called nistead of 911. This part of the story doesn't make sense to me- he can't be falling and too disoriented to give proper consent, while simultaneously only requiring non-emergent transfer.
While the paramedic's actions as described need to be addressed, so does this aspect as well.
Hypo, I tried to address that. I'm with you. IF the patient presented exactly as described, with no other info, I would call that an emergency. In such a scenario, I suggest that call for 'non-emergent' transport is a mistake. That's what I was trying to get across for future reference.
Altered LOC is a sign of an emergency until established otherwise.
In my previous comment, I meant to answer your question (about the nurse's action) even before getting on the medic.
Given only the info in the OP, I think the nurse needs to consider different action for the future. I think the medic needs to have his head handed to him.
I don't know what state you are in, but in my state, all EMS agencies (including critical care transports) are required to get medical advice (usually from the ER docs where the patient would be transported) on the acceptance of a refusal of transport. If this paramedic made the decision without contact for physician approval, he could lose his certification in the state I live in.
Just as a post script, it is not uncommon to encounter this kind of cowboy attitude in the rural setting. I work professionally as a transport RN, but also volunteer on a rural ambulance in the community that I live in. One of the most aggravating things I face is the cowboy attitude of a few of the volunteer EMT's. Some become EMT's for the t-shirt and the privilege of strutting around the community with their inflated ego's. On the other hand, we also have some very dedicated volunteers that take their job seriously and have excellent skills. Sadly, it only takes a few cowboy's to ruin the reputation of the good EMT's. Hopefully, this one paramedic in your situation hasn't ruined the other's on his service.
Boy do I know this one. Try having a person call for the ambulance and then try to give you a DNR paper for the person that is lying on the floor unresponsive and no pulse . FYI .. If the person has a DNR don't call the ambulance right away... We can't abide by your paper. We have to do CPR and try to save the person ... Also, as a former EMT I would never let a person refuse treatment without contacting medical command for the go ahead and if you do refuse treatment you have to sign off.. Yep the cowboy attitude lives on .. I would contact the county and state about this . If nothing happens go to the paper and news station..
Boy do I know this one. Try having a person call for the ambulance and then try to give you a DNR paper for the person that is lying on the floor unresponsive and no pulse . FYI .. If the person has a DNR don't call the ambulance right away... We can't abide by your paper. We have to do CPR and try to save the person ... Also, as a former EMT I would never let a person refuse treatment without contacting medical command for the go ahead and if you do refuse treatment you have to sign off.. Yep the cowboy attitude lives on .. I would contact the county and state about this . If nothing happens go to the paper and news station..
BAMBI, this must vary among states and among services. It might even make a difference if the crew is BLS or ALS, though I've never seen that.
For one thing, everywhere I've worked as a medic (in Mass. and NM) we have honored valid DNRs. The problem is slowing down the adrenaline to read it and make sure the thing is still current and signed by the doc, etc.
In addition, we have always had autonomy in dealing with patient refusal of care. If we have doubts or want the doc to try and convince the patient, then we get on the phone. But 99% of the time it has been our authority and judgement to decide if a refusal is an acceptable option.
So, I think we can't make a blanket statement here for all locales. What is true, as that anyone interacting professionally with local EMS services should be informed by them at a joint training or the like what their protocols are and how particular situations should be handled.
In Texas, there's a separate "out of hospital" DNR a patient must have (and most do). We don't honor in-hospital DNRs or generic living wills, though I'm not sure if this was my particular unit's policy or a state policy.
Boy do I know this one. Try having a person call for the ambulance and then try to give you a DNR paper for the person that is lying on the floor unresponsive and no pulse . FYI .. If the person has a DNR don't call the ambulance right away... We can't abide by your paper. We have to do CPR and try to save the person ... Also, as a former EMT I would never let a person refuse treatment without contacting medical command for the go ahead and if you do refuse treatment you have to sign off.. Yep the cowboy attitude lives on .. I would contact the county and state about this . If nothing happens go to the paper and news station..
I don't know what the policy is in your state, but in mine, we honor valid out of hospital DNR forms and DNR bracelets issued by the state medical society. Further, a family might reasonably call an ambulance for a DNR patient who is in distress - it's not Do Not Treat, after all.
For the OP, I agree, emergency transport was required. Apneic? Emergency. In this state, a disoriented, semi-conscious patient would be transported by "implied consent" - that is, we presume, were he conscious and oriented, he would choose treatment like a rational being (as we define it.) This paramedic - he's a EMT-P? Amazing. His little hiney needs to be reported to the appropriate board - unless your state is so cowboy all the way that he was right by state standards. Doubtful, though.
I got a little ticked (understatement) and said "He's barely conscious, he has fallen, he cannot adequately answer questions, and you think he's coherent enough to make that decision on his own????" Paramedic got a little ticked (understatement) and began to lecture about how it's false imprisonment to force a patient to go to the hospital, and I really need to calm down here......That's when I REALLY lost it (not proud of that, but it happened) and said "I wouldn't have called you if I hadn't needed you. He is not capable of making a sound decision at this point in time. We need to get him to a safe place." Paramedic then tells me "It's MY ambulance (it is, really) and I get to say who gets to ride in it. You can't tell me what to do." I looked at him and said "Well, walk out and I WILL report you for abandoning the patient." Then it got a whole lot uglier from there verbally.
. She smoothed it out and patient was transported. Turns out he had overdosed on medications. I found out later there is a law in my state that says if a patient is incoherent, they are incapacitated and MUST be transported to a higher lever of care. I AM FURIOUS. Was I wrong? And should I just let this go or complain officially? Any advice appreciated.
hypocaffeinemia, BSN, RN
1,381 Posts
It's not this way in Texas. We just chart the refusal, sometimes without even getting ID-- back when I was active EMS we'd show up at MVCs where everyone was superficially fine and everyone rejected EMS treatment and transfer on a daily basis.