Editor's note: The first part of this article introduced the major issues involved with non-transport calls, including the results of a few legal cases involving medical patients. Part 2 discusses two historical trauma cases, destination decisions and system abuse.
No transport in trauma cases
Trauma cases pose their own difficulties, since patients who may not initially appear to be injured may later turn out to have serious problems. In one negligence case, EMS left an accident scene after evaluating a patient named Faith Hackman, but she subsequently lost consciousness and they were called back to the scene.(1)
Paramedics initially arrived on scene two minutes after they were dispatched, and found Hackman and a law enforcement officer standing next to her vehicle. The providers stated that they conducted a "visual and interactive" evaluation of Hackman's condition, noting that she was breathing, responded verbally and appropriately to questions, that she could move all of her extremities, and that her skin color was appropriate. The paramedics concluded that she was not injured, and she told them she was fine and did not want to be transported to a hospital. About 20 minutes after the paramedics left, Hackman collapsed. EMS returned and transported her to a hospital. She later filed a lawsuit against the paramedics, alleging that they abandoned her.
The paramedics didn't have Hackman sign an "against medical advice" (AMA, or refusal form) because they didn't believe she was injured. They testified that if they had believed she needed treatment, they would have strongly encouraged her to accept treatment, and had she refused, they would have asked her to sign the form. The court found in favor of the paramedics only because they had not begun treatment.
In an Ohio case, EMS failed to transport a trauma patient who subsequently died of an epidural hematoma.(2) In this case, the call was for a patient found lying outside the door to his apartment by his brother. His brother summoned EMS and helped the patient inside, noting that the patient had blood coming from his nose and mouth. The patient said he had fallen. When interviewed, the patient gave his age as 18, when he was actually 24. One of the EMS providers used an ammonia capsule to stimulate him, and said that if taken to the hospital, he would be put on a floor for mental patients.
EMS then left, telling the family to call back if the patient's condition worsened. The patient's condition deteriorated almost immediately, and the family called 9-1-1 again. After a 45-minute delay, EMS transported the patient, who subsequently died.
At trial, the providers testified that the patient was uncooperative and refused to be transported. The county coroner testified that the patient died of an acute epidural hematoma, secondary to blunt trauma to his head. In this case, Ohio provides immunity for all but "willful and wanton" conduct by EMS personnel, and the providers escaped liability.
As evidenced by these cases, a number of factors merit consideration before an EMS decision is made against transport in a trauma case. The mechanism of injury, if known, and the likelihood of the patient's demise after EMS evaluation should be weighed. Even if a patient with obvious bleeding, head injuries and bruising "waves off" EMS, they should be evaluated for a potential life-threatening injury. In addition, unlike epidural hematomas, subdural hematomas may be slow to form, and a patient who appears without deficit may deteriorate over a period of time after EMS leaves. A full set of vital signs, repeated at least once to document any changes from the baseline, and a hands-on, head-to-toe evaluation (including a neurological evaluation) should be performed, and well documented, including pertinent negatives.
EMS personnel are familiar with the "farthest hospital rule"; it seems that patients always choose a hospital that's farthest away from the scene. Patient destinations may be a matter of patient choice, but a number of situations may allow EMS to "override" the patient's destination decision.
Rural EMS agencies with limited resources may elect not to transport to distant hospitals, instead taking patients to closer facilities where they can be evaluated and then transferred by urban non-emergency ambulance services if needed. EMS may also override a patient's choice of destination because the hospital that the patient chooses does not have the appropriate services.
Contrary to popular belief, patients do not have a "right" to be transported to the hospital of their choice. For example, patients having cardiac-related chest pain should not be transported to facilities without cardiac catheterization labs when other, more appropriate facilities are nearby. Local protocols will usually determine the appropriate destination for critically injured trauma patients, and are also likely to address the types of patients who should be transported to the available facilities within the service areas.
Liability may attach when EMS takes a patient to a hospital that does not have the means to care for them, particularly if EMS chooses that destination against the patient's wishes. In a Michigan case, EMS responded for a patient who had suffered an acute stroke.(3) The patient's wife requested transport to Spectrum Health in Grand Rapids, but EMS took him to Mecosta County General Hospital instead. After a CT scan, the hospital determined that the stroke was caused by an embolus, but failed to administer thrombolytics and failed to transfer the patient quickly to another hospital. The patient finally arrived at Spectrum after the three-hour window for administration of thrombolytics had elapsed, and he sued for "loss of chance," alleging that the failure of EMS to take him to Spectrum as requested caused him to lose the chance of recovery he might have had if the thrombolytics had been administered. He suffered paralysis and severe neurological damage from the stroke.
Initially, the court dismissed the case because the damages were speculative, and the appellate court dismissed the case because the plaintiff was unable to demonstrate that it was probable that the failure to administer the drugs caused him the loss of greater than a 50% opportunity to achieve a better result, which is required under Michigan law.
EMS system abuse
Clearly, there are times when callers abuse the EMS system, and providers are tempted to refuse transport-or at least to strongly encourage the caller not to be transported. A 1999 study of inappropriate use of EMS transport services compared the provider and patient perspectives.(4) The study concluded that inappropriate use of EMS transport services is a significant problem from both the provider and patient perspectives, and found that certain patient characteristics were associated with a higher probability of appropriate and inappropriate uses.
Chronic system abusers should be dealt with administratively by the EMS service's administration and the patient's primary care providers (PCP). A few good approaches can resolve this problem, and ultimately EMS medical directors and services must decide what level of risk they're comfortable in taking, because there will always be risks with chronic 9-1-1 callers. The best approach is to attempt to deal with the chronic caller via administrative channels, if possible, by putting the EMS administration in touch with the patient's PCP. If the patient is homeless or has no PCP, there may be no good solution to chronic calling.
Be very conservative in making transport decisions. Remember that a patient's signature on a refusal of transport form does not absolve EMS from responsibility for that patient's well-being, and that courts have found signatures invalid when they fail to represent a fully informed refusal based on a careful and complete patient assessment. Use extreme caution before telling a patient they "don't need" EMS transport. Always inform a patient of the possible consequences of not going in to the hospital via EMS. When encountering patients who report a recent emergency situation, strongly encourage them to go in with you for follow up, even if they are feeling better and appear stable by the time you see them. They may be sicker than they look.