JEMS Clincial Review Feature
This clinical review feature article is presented in conjunction with the Department of Emergency Medicine Education at the University of Texas Southwestern Medical Center, Dallas.
Adult epiglottitis: A severe, potentially life-threatening inflammation of the epiglottis, which is posterior to the base of the tongue and covers the tracheal entrance as swallowing occurs.
Non-transport: A patient contact that results in a patient not being transported by the EMS crew.
Differential diagnosis: A list of possible illnesses and injuries that should be considered based on available signs and symptoms.
Co-morbidity: Medical conditions that exist simultaneously and may complicate another medical illness.
Tachycardia: A resting heart rate greater than 100 beats per minute.
Bradycardia: A resting heart rate lower than 60 beats per minute.
>> Recognize the risks involved in non-transport of patients who have been evaluated by EMS.
>> List criteria for non-transport patients at high risk for adverse outcomes.
>> List five strategies to convince patients they need to be evaluated by a physician.
This best-evidence article will help you become more aware of the non-verbal messages responders send and help you navigate the balance between a patient’s right to refuse transportation and the safety risks this creates.
“Really?” my partner exclaimed as the police officer passing us muttered something about a sore throat. My partner wasn’t happy. “Are you cancelling us?” she asked.
“Nope, he wants to talk to you,” the officer responded with a grin.
After we entered the house, the 54-year old patient explained that he had coughing fit and couldn’t catch his breath, which prompted him to call 9-1-1. “Now it’s just a tickle in my throat; I’m OK,” he explained. “I’m sorry. This is embarrassing, but I don’t really want to go to the hospital.”
My partner started shaking her head as she walked out of the house with our monitor and bags. “I’ll wait for you in the truck,” she growled.
But a nervous paramedic student accompanying us was about to make the scene much more interesting. “Doesn’t this meet high-risk refusal criteria?” he asked.
My 25 years of experience prevented me from rolling my eyes as I prepared to give my “common sense versus protocol” lecture. Instead, I invited the student to elaborate. The student replied that the patient called 9-1-1 because he was short of breath. “Are you still short of breath?” I asked the patient.
“Nope,” he answered.
“Sign here,” I said, handing him a refusal form.
“But, aren’t we supposed to call medical control?” the student insisted.
Although I was starting to get annoyed, he was technically correct. In fact, he was referring to an evidence-based policy I helped craft five years earlier. Although this patient was now “feeling fine,” studies show that patients with complaints of respiratory distress are at risk for serious conditions that may not necessarily be evident at the time of an EMS evaluation.1–8
The practice of calling a medical control physician is meant to slow down the refusal of the care process and force the patient and crew to reconsider their position by consulting a higher medical authority.1,9–12
As I began the process of contacting the physician, I was confident that it would result in a brief 30-second conversation which would ultimately result in the patient not being transported.
Fortunately, my student’s insistence on calling medical control saved the patient’s life. The patient, now pressured to speak in a louder voice over the radio with the physician, was forcefully coughing again. I asked the patient’s wife if his voice always sounded this raspy, and she replied that it didn’t. She also noted that her husband had been coughing and drooling all day.
The patient now sat in a tripod position and made a high-pitched grunting sound as he handed me the radio, his breathing obviously labored. Clearly, we had a different case on our hands than what we first suspected. Instead of requesting a refusal, I asked for orders to administer nebulized epinephrine. Thirty seconds later, we rushed out the door, and I told my confused partner to drive to the closest emergency department (ED).
The patient in this case was suffering from adult epiglottis. We administered epinephrine in the ambulance, which kept his airway patent until he received an emergency tracheotomy at the receiving hospital.
Statistics show that non-transports of patients calling 9-1-1 occur between 5–30% of the time.6,11 In this case, initial scene information led two experienced paramedics to get tunnel vision and search for confirmation of an erroneous diagnosis—a sore throat. We dismissed the patient’s complaints as non life-threatening and were overconfident in our assumptions. We had made judgments about a patient’s condition based on our internal biases or subconscious assessments.9
Let’s Be Honest
Street medicine isn’t always so cut and dry. It’s filled with mixed messages. For example, we encourage the public to call 9-1-1 but often get frustrated if patients aren’t having a life-threatening emergency when we arrive.
The public believes they’re calling 9-1-1 to get help and not necessarily to be transported to a hospital. Yet many EMS policies are written so that a 9-1-1 call essentially means the patient will be transported. It’s also the case that many EMS crews may send unintended messages that suggest the patient shouldn’t be transported.
After all, EMS is just as much an assessment and referral service as it is a “life-or-death” intervention service. Although providers must focus their training on recognizing and caring for life-threatening conditions, the majority of our patients aren’t in critical condition. Our job is to fully assess each patient, and we should be open to any condition that might cause harm to them, not just the ones that will kill them in the next few minutes.
In fact, several studies performed in systems that don’t allow EMS-initiated transport refusals concluded that the decision to refuse transport wasn’t just the patient’s, but rather a mutual decision made between the EMS crew and the patient.13,14 In short, our patients look to us as responders to help them assess the severity of their own conditions, and sometimes the indirect messages we send to our patients can affect major decisions.
Does EMS actively discourage transport? Perhaps, but more likely EMS crews may send unintended messages that suggest non-transport. The arrival of EMS and a calming assessment often de-escalates a situation. This is especially true when the communication from EMS providers on scene directly or indirectly implies that the patient isn’t experiencing an emergency.
In the case described above, the indirect messages we sent the patient were fairly clear: We displayed frustration at the perceived 9-1-1 system misuse, and we handed the patient a refusal form before fully assessing him.
In other cases, non-verbal cues may be more subtle and well-meaning, such as reassuring a patient their blood pressure is OK or their ECG is normal. We might ask patients whether they have a friend who could drive them to the hospital instead, or let them know that no treatment will be necessary during transport. The hidden message is that the patient isn’t experiencing a true medical emergency. And our patients will often heed these cues.
Not all patients who refuse transport are created equal. Some patients fall into high-risk refusal categories. These patients are more likely to have serious conditions that are being masked or could be slowly developing and result in grave consequences if left untreated.
Age: For many reasons, patients who are at extremes of age may be at especially high-risk. Pediatric patients are often difficult to assess and tend to mask signs of shock or other serious illness.3,8,15–17 EMS providers respond to fewer pediatric cases, making these cases more challenging and uncomfortable.18,19
Multiple studies have focused on older patients who refuse care.2,6,20 Patients who are 65 or older are more likely to call EMS back within three days of their first call for help and are more likely to die within one week of their original request for service. When EMS responds to a “lift-assist” call to put an elderly patient back into bed, providers should be asking why the patient is unable to get up. Weakness, inability to stand or bear weight, confusion and morbid obesity may have other co-morbidities.
Another reason might be that they’re influenced into thinking their emergency doesn’t require transport. In one study, 20% of older patients who refused transport did so because EMS providers implied no transport was needed, and 50% said contact with a physician would have changed their mind.20
One reason older patients might refuse care is financial. Older patients are often on a fixed income and may not want treatment because of the cost.
Physiological parameters: Obtaining a full set of vital signs can help identify a high-risk patient. Persistent abnormal pulse rate, blood pressure, respiratory rate, temperature and pulse oximetry require a more thorough medical evaluation. Tachycardia or bradycardia should cause enough concern to recommend transport. See Table 1 (JEMS, December 2010, pg. 58) for other triggers. If the patient still refuses transport after you’ve explained the abnormality, you should wait and re-check vital signs before carefully documenting the patient’s refusal.
Mind-altering substances: Unfortunately, it’s often impossible to tell if someone under the influence is really hurt.21 The mind-altering and anesthetic qualities of these substances make patients feel good even if they have serious injuries or illnesses. Some guidelines can help you decide whether to triage, detox or transport a patient to the hospital: verifying the patient is fully alert, oriented and able to understand the seriousness of their condition; ensuring the patient can walk, talk and make sense without assistance from others; verifying that a sober person is available to monitor the patient’s airway; and determining the time and amount of ingestion is neither recent nor extreme.
Hypoglycemia, hypoxia and metabolic derangements should always be suspected first. Using a mnemonic, such as AEIOU TIPS, might help you recall the many reasons for altered mental status (see Table 2, JEMS December 2010, pg. 59). You should rule these factors out before concluding that alcohol was the primary reason for the altered mental status.
Alcohol-impaired patients with a head injury, even a minor one, are prone to sheering of blood vessels and serious brain injuries.22
Blood thinners and trauma: Factors that complicate simple trauma include prescription medications, especially blood thinners (e.g., Warfarin, Coumadin and Plavix) and Beta Blockers (e.g., Atenolol).
Police custody: Patients in custody can present serious challenges. If criminal activity is suspected, law enforcement may be eager to have the prisoner “medically cleared” for incarceration or further questioning. It’s important that the EMS provider not feel undue pressure to expedite the medical assessment. Adverse medical and legal cases abound in which patients in police custody were assumed to be over-dramatizing symptoms. Later, responders found out that they suffered from conditions that were lethal when untreated, such as hypoglycemia or heart problems.23–25
EMS and law enforcement share a duty to protect the patient and ensure proper medical care is given. New research on excited delirium and the effects of mania, as well as forcible restraint with pepper spray and Taser use, should prompt EMS to perform careful and thorough assessments and err on the side of hospital evaluations.
Other conditions/situations: A few other miscellaneous conditions should be considered high risk. These involve first-time seizures, especially associated with a fever in a child. Remember that febrile seizures are a diagnosis of exclusion.
Be concerned for a patient who just had a Heimlich maneuver performed. These patients may have internal injuries due to the force of the procedure.
Extremely cold temperatures may also complicate an assessment, as aches and pains from a fall or car crash won’t be felt until the patient’s body warms up.
Seek training to recognize which soft tissue injuries will require stitches or immunizations based on your local area. One study showed that EMT-Bs can have a high degree of accuracy in determining the need for stitches for lacerations, but only after proper training and experience was monitored.26
Low-Risk Non Transports
In contrast, some patients can be considered low-risk non-transport patients. For example, research shows that some diabetic patients treated on scene may be safely treated in the field within the right parameters.27,28 Hypoglycemia from a known cause in a patient who is insulin-dependent and responds well to a field administration of dextrose will often be a safe non-transport. However, it’s important to note that these patients should be accompanied by a person who can help monitor their blood glucose level and call EMS back if necessary. Patients on oral hypoglycemic agents, such as glyburide, metformin and avandia, may require long- term medical monitoring and generally aren’t safe to refuse transport.
Keep in mind that if the patient having a diabetic reaction was violent or required repeat doses of dextrose to wake up, especially in older adults with co-morbidities, a more detailed exam and advanced diagnostics (including a 12-lead ECG evaluation) are recommended.
Ultimately, online radio medical direction can help determine whether a patient will need to be evaluated in the ED.
This article is meant to provoke thought and stimulate EMS providers to proceed with caution when a patient appears to be refusing care (see “Rules to Live By,” p. 60). Under most circumstances, an alert patient of sound mind should be allowed to refuse transport, but only after a detailed conversation has taken place in which the patient is educated about their choice. Patients should be encouraged to call EMS back if they change their mind.
If you’re treating a patient who meets the high-risk categories described in this article but still refuses transport, try the following tips:
- Watch your non-verbal and verbal communication so you don’t send an inadvertent message that refusal will be mutually acceptable.
- Explain the seriousness of their condition and potential dangers, including possible death, if they don’t accept care.
- Have a supervisor or family member speak to a patient who’s injured at work.
- Put the patient in direct contact with a medical control physician who may have better luck convincing them. Also, a recorded voice conversation will help protect you should legal action occur in the future.1
- Consider forgiving the patient’s bill. If this isn’t your agency’s policy, speak to your supervisor or senior management about it.
- Keep your guard up with a high index of suspicion if physiological and other parameters are abnormal, and re-assess vital signs until they’re within normal limits or the patient accepts transport.
If you try all these techniques and discover there’s no way to convince the patient to accept transport, be sure to obtain detailed documentation that includes signatures of witnesses who can confirm the refusal is against your medical advice. JEMS
- Alicandro J, Hollander JE, Henry MC, et al. Impact of interventions for patients refusing emergency medical services transport. Acad Emerg Med. 1995;2:480–485.
- Moss ST, Chan TC, Buchanan J, et al. Outcome study of prehospital patients signed out against medical advice by field paramedics. Ann Emerg Med. 1998;31:247–Stratton SJ, Taves A, Lewis RJ, et al. Apparent life-threatening events in infants: high
- risk in the out-of-hospital environment. Ann Emerg Med. 2004;43:711–717.
- Burstein J, Henry M, Alicandro J, et al. Outcome of patients who refused out-of hospital assistance; Am J Emerg Med. 1996;14:23–
- Sucov A, Verdile VP, Garrettson D, et al. The outcome of patients refusing prehospital transportation. Prehospital Disaster Med. 1992;7:365–371.
- Knight S, Olson LM, Cook LJ, et al. Against all advice: an analysis of out-of-hospital refusals of care. Ann Emerg Med. 2003;42:689–696.
- Pringle RP, Carden DL, Xiao F, et al. Outcomes of patients not transported after calling 9-1-1. J Emerg Med. 2005;28:449–
- Silvestri S, Rothrock SG, Kennedy D, et al. Can paramedics accurately identify patients who do not require emergency department care? Prehosp Emerg Care. 2002;6:387–90.
- Bultman L, Ho J, Page D. Undesignated Patients: Where Do They Go and Why? Hennepin County Medical Center, Minneapolis, Minnesota. Abstract accepted for presentation at NAEMSP symposium, 2005. Available online at: www.naemsp.org.
- Burstein JL, Hollander JE, Delagi R, et al. Refusal of out-of-hospital medical care: effect of medical-control physician assertiveness on transport rate. Acad Emerg Med. 1998;5:4–8.
- Cone DC, Kim DT, Davidson SJ. Patient-initiated refusals of prehospital care: ambulance call report documentation, patient outcome and on-line medical command. Prehosp Disaster Med. 1995;10:3–9.
- Niegelberg E, Pesce K, Cox L, et al. 210: The impact of online medical direction on ambulance transport of patients initially refusing medical assistance. Ann Emerg Med. 2010;56:S69.
- Persse D. The effect of a quality improvement feedback loop on paramedic-initiated nontransport of elderly patients. Prehosp Emerg Care. 2002;6:31–35.
- Page D, Klann L, Lick C, et al. True Refusal or Mutual Decision? Perception, satisfaction, and follow up of high risk patients after EMS non-transport; poster abstract presentation. Prehospital Care Research Forum. March 2006: Baltimore.
- Seltzer A, Vilke G, Chan T, et al. Outcome study of minors after parental refusal of paramedic transport. Prehosp Emerg Care. 2001;5:278–283.
- Patterson P, Baxley E, Probst J, et al. Medically unnecessary emergency medical services (EMS) transports among children ages 0 to 17 years. Matern Child Health J. 2006;10:527–536.
- Haines C, Lutes E, Blaser M, et al. Paramedic initiated non-transport of pediatric patients. Prehosp Emerg Care. 2006;10:213–219.
- Cushman J. Ambulance personnel perceptions of near misses and adverse events in pediatric patients. Prehosp Emerg Care. 2006;14:477–484.
- Haines C, Lutes E, Blaser M, et al. Paramedic initiated non-transport of pediatric patients. Prehosp Emerg Care. 2006;10:213–219.
- Vilke G, Sardar W, Fisher R, et al. Follow-up of elderly patients who refuse transport after accessing 9-1-11. Prehosp Emerg Care. 2002;6:391–395.
- Guttenberg M, Asaeda G. Under the Influence. JEMS. 2002;27:50–59.
- Shah M, Bazarian J, Mattingly A, et al. Patients with head injuries refusing emergency medical services transport. Brain Inj. 2004;18:765–773.
- O’Boye S. Grand jury says simple steps could have saved man killed by police pepper spray. Fort Lauderdale Sun-Sentinel. March 4, 2004.
- McBride J, Fauber, J. Heart irregularity blamed in Mallett’s death; Jones admits officers did not monitor man in custody as required. Milwaukee Journal Sentinel. January 9, 2002.
- Man dies in police custody. AP Newswire. May 27, 2004.
- Hale D, Sipprell K. Ability of EMT-Bs to determine which wounds can be repaired in the field. Prehosp Emerg Care July-Sept. 2000;4:245–249.
- Lerner E, Billittier A, Lance D, et al. Can paramedics safely treat and discharge hypoglycemic patients in the field? Am J Emerg Med. 2003;21:115–120.
- Cain E, Ackroyd-Stolarz S, Alexiadis P, et al. Prehospital hypoglycemia: The safety of not transporting treated patients. Prehosp Emerg Care. 2003;7:458–465.
- This article originally appeared in December 2010 JEMS as “Walk the Line: Which refusals can risk patient safety—and your career?”
Rules to Live By
- If they want transport, just do it. Otherwise, you’ll spend more time and effort and put yourself at considerable risk.
- If they can’t walk, talk and make sense, find a way to convince them to go. If EMS has already been called to the scene for this problem and the patient refused the first time, make sure they’re transported the second time.
- If you work in cold temperatures, make sure you’re assessing patients in warm environments and waiting for their full-body ice pack to wear off before you leave the scene.
- Be curious about the outcome of your patients. When possible, follow up to find out if your assessment hunches were right.