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Patient Abandonment Part Two

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Update: The state EMS office in Massachusetts is now reconsidering a reminder an edict that an ambulance with a patient on board may not stop at the scene of another medical emergency.

The state EMS office in Massachusetts recently sent a reminder out to its EMS services indicating that an ambulance with a patient on board may not stop at the scene of another medical emergency. The notice states that the office has received information that some EMS services have policies that instruct them to stop at the scene of a crash even if they are transporting another patient, and that such policies are "invalid and without legal force." This issue has also arisen in the context of EMS units who, while responding to calls, encounter another emergency en route or who may be en route to a low priority or "alpha" call when they find themselves the closest unit to a higher priority call. What should EMS do in these situations?

The lawyer's favorite answer: it depends. As Dr. Jeff Clawson reminds us in his latest edition of Principles of Emergency Medical Dispatch, "The good of the many outweighs the needs of the few or even the one." Ultimately, these situations will result in judgment calls, and every situation is different. Each state has its own EMS legislation and laws affecting medical transportation, and these laws must be considered as a framework for the difficult decisions we'll face.

It will also be important to consider your system configuration, the acuity of the patients involved and the availability of additional units when the moment occurs. The public's perception of EMS and its duties is another factor, and an entire EMS system can be sued for patient abandonment when we fail to provide the services the community expects of us. It's without question that public perception will not be in your favor if an EMS unit passes by an injured patient when it's not transporting another patient, but is instead en route to a low priority call.

This isn't a simple issue, and it's a difficult one to cover in EMS protocols, although a protocol should provide some guidance as to the factors that go into the decision you'll need to make. Clearly, the EMS medical director should weigh in on how this situation should be evaluated by dispatchers and responding EMS units. The use of a medical priority dispatch system is greatly beneficial in providing the "big picture" of how to best cover periods of time when multiple EMS calls arise and situations rapidly evolve -- and how to get the right units to the right patients in the right time frame. It isn t at all uncommon for dispatch to "divert" a responding unit from an "alpha" or low priority call to another, higher priority call that the responding unit is near. Last, but certainly not least, EMS services should never let their financial interests interfere with their true mission of providing quality emergency care to the community.

Situations may exist in which stopping with a patient on board is appropriate in some EMS systems. "Medically and ethically it boils down to a risk benefit calculation," says Dr. Mark Hauswald, Professor Emeritus/Associate Dean of Clinical Affairs at the University of New Mexico in Albuquerque. "If the patient being transported is unlikely to be harmed by the delay and the new patient is likely to benefit, then stopping is the right thing to do. If the situation is the reverse, then don't." Dr. Hauswald reminds us that "the devil is in the details" and that it's important to obtain and weigh as much information as possible about the patients involved. It may also be appropriate to ask the patient you re transporting for permission to stop at an accident that presents itself en route.

Another morphology of this issue arises when an EMS unit isn't transporting a patient but has been dispatched to a call when another, perhaps more serious call, arises or the unit encounters an accident en route. This issue may be handled differently by private EMS services than by public EMS. If a private EMS service is the only transport unit in a given area, it may have different responsibilities than units in areas with multiple services that have transport capability. Public EMS' obligation is always to the public. Should a public sector EMS encounter an accident while en route to an "alpha" or non-emergency call, the crew should call for another unit immediately, stop and triage the situation, and make a decision based upon what they find. If you encounter a critically ill patient, there isn't much question what you should do. When I worked in a busy fire department, we had three paramedics to a truck and would sometimes leave one paramedic with a jump bag on a scene to triage and await a transport unit, while the truck went on to another call. There are many ways to handle these situations in a manner that quickly gets the highest level of care where it's most needed.

If you're en route to a non-emergency transfer call, and the patient you're called to transport is in a medical facility, it would be reasonable to stop at another scene to triage and have another unit dispatched to the transfer call. Delay in patient transfers may cause a different set of problems, and should be avoided whenever possible. Some EMS services have taken the position that a contract exists between the transfer patient and the service that renders the EMS unit unable to stop at an emergency they encounter en route, or that the presence of one call creates an unwritten contract between the first patient and the EMS unit enroute to that call. However, it cannot be understated that the EMS system as a whole has a duty to do what's best for the most people it can in every situation, and the patient s acuity level -- not the financial interests of the EMS service -- should always dictate how these situations are handled.

JEMS.com Editor's Note: Want to know more about the legalities of patient abandonment? Check out W. Ann Maggiore's October article, "Patient Abandonment: What It Is -- and Isn't."

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