Eye of the EagleDavid P. Keseg, MD, FACEP
Wednesday, June 27, 2007
There are some circumstances when patients may receive treatment from EMS providers but ultimately refuse to be transported to the hospital.
For example, a diabetic patient in hypoglycemic coma might regain consciousness after receiving IV glucose. The patient decides that they feel fine and refuses to be transported to the hospital. Another example might be in the case of asthmatic or COPD patients. They may get an Albuterol/Atrovent treatment, feel their breathing becomes easier and feel that it is not necessary to go to the hospital.
Finally, there have been a few instances where patients who have a problem with Supraventricular Tachycardia (SVT) that may be associated with a chronic cardiologic diagnosis, such as Wolf-Parkinson-White (WPW) syndrome, call 9-1-1 when they are in SVT. After receiving IV Adensine and being converted to a normal sinus rhythm, they then elect to reject the advice of the EMS providers to go to the hospital.
In all of these instances, it puts the EMS provider in a difficult and uncomfortable position.
It is important to understand when dealing with these patients that they do have the right to refuse transport if they have a normal level of consciousness that has not been altered by drugs, alcohol, hypoxia, hypoglycemia, head trauma, hypoperfusion or any other physiologic process that would affect the patient's ability to make a judgment concerning their well being. Even if you have gone out of your way to convince the patient of the necessity of going to the hospital and have thoroughly explained the risks and consequences of not being transported, the patient may decide not to go. In those cases, it is extremely important to do the following:
- Make sure and document your run report thoroughly. You should try and record the actual phrases or words you used to convey the severity of the patient's condition and why it was in their best interests to be transported to the hospital. You can say things like: "I explained to the patient that their heart might begin to beat rapidly again and that there is no way we can assess the damage done to their heart without them agreeing to be transported to the ED for a full cardiac exam."
- Explain the risks and benefits of being transported to the hospital in the presence of as many witnesses as possible. Whether it is your fellow EMS providers, EMS supervisor, family, friends, police, or whatever, make sure others witness your attempts to convince the patient to go to the hospital. Then if possible, have the witnesses sign your run report as to the validity of your written record of your efforts.
- Remember to use your diagnostic tools to validate your assessment of the patient's level of consciousness. For example, if your protocol says that before we can leave a diabetic at home who has suffered a hypoglycemic episode and been given D50, you need to make sure that their post-D50 glucose level is 80 or above. If you have a patient with hypoxia from asthma or COPD, you can use your pulse oximetry unit to make sure that their oxygenation level is normal for them and that they are not hypoxic. This further serves to validate your assessment that the patient has a normal level of consciousness.
- Involve your EMS supervisor in these cases, if available. They may be able to serve as a facilitator and mediator to allow the best possible result to occur in these cases. At the very least, they can help to witness your attempts to try and convince the patient to act in their own best interests and may have some helpful hints on situations that they may have encountered.
- Try not to take it personally. One of the natural things that EMS providers feel in these situations is frustration and anger. The fact that you are trying to help these individuals and that they are ignoring your counsel may result in you feeling bitter and may interfere with your ability to treat the patient in a professional manner. When these incidents occur frequently with the same patient, you may feel used and taken advantage of and may feel tempted to refuse to render care to these patients. Don't ever withhold care from a patient who obviously needs an urgent intervention that is required in our protocol to perform in order to "blackmail" a patient to allow you to take them to the hospital. You may continue to run on patients who will just get that initial dose of Adenosine and then sign off. But the fact is they need that intervention whether they go to the hospital or not, so it is important for the EMS provider to remember that. Try to approach them in the same way you would render care to any prehospital patient.
- If you work with a base station or call center, involve the appropriate personnel in your decision-making process. Sometimes getting a physician to talk to these difficult patients can help them change their minds and agree to be transported.
The bottom line on these patients is to continue to treat them in a professional manner and document your run reports to reflect their own decision to refuse transport in spite of your best efforts to convince them otherwise. If you feel that specific situations rise to the level of 9-1-1 abuse, then approach those on a case by case basis and try to determine a remedy for these individually. It is best to send these cases up the chain of command through your EMS supervisors.
David P. Keseg, MD, FACEP is the medical director for the Columbus Division of Fire.