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Our patient was sitting on the couch. He was conscious, alert and oriented. He denied chest pain or difficulty breathing. Our initial assessment found that his vital signs were within normal limits, and that he had no specific complaints.
His daughter was distressed because she was having difficulty taking care of him. She said that he was too weak to make it up and down the stairs to his bedroom on his own, and she was having trouble coping with the situation. Her father had been seen in the emergency department (ED) the previous day for the same complaint and had been released without a specific diagnosis.
Considering the patients' and family's best interests, I explained that this did not appear to be an acute problem that could be solved through the EMS system. Since he had been seen at the ED for the same complaint the previous day and discharged home, what did the daughter suppose would be different today? I suggested that perhaps he needed nursing care (that didn't go over well). I suggested perhaps they should contact his primary care physician to discuss options. I even got on the phone for them. The doctor wasn't available, so I left a message to have him call back.
We spent probably an hour at the house. We got a statement of refusal signed and told the family to call back if they needed us. I felt very good about the fact that we had put thought and effort into trying to address the patients' and family's problem, rather than just loading him up and taking him to the hospital, saddling the family with another large bill and no solution.
The next day I got a call from my boss. The family had called again later in the day, after my shift had ended. The crew ALSed the patient to the ED, where he was diagnosed with myocarditis and admitted. My boss asked me why I shirked my duty to transport the patient to the hospital. My job was to transport patients, she told me, not to do social work. I offered to call the family to try to straighten things out (lesson: always a bad move).
I spoke to the patient's wife, who berated me at length for being uncaring and arrogant. She was not in the least receptive to my explanation that I was actually trying to be caring and sympathetic. Rather than a compassionate hero, she viewed me as a callous cad who refused to help her husband in his hour of need.
Of course, I was wrong, the patient was sick and needed to go to the hospital. The easy way is to always transport, no questions asked. It is remarkable how many paramedics expend extraordinary efforts to obtain refusals, when really the path of least resistance is to load em up and ship em out. But what about patient advocacy in a broken health-care system? Does getting it wrong one time mean never trying to get it right? One concrete lesson I think is to avoid having to make such decisions on your own if you can help it turf to medical control, and share the love.
Would I do it again? I'm not sure. With the years, idealism necessarily suffers, or is tempered by the realism of experience your choice. Still, it's sometimes hard to ignore that "patient advocacy" thing, even though we all know that the road to hell is paved with good intentions, and life will let no good deed go unpunished.
