At 2030 HRS, an ambulance and crew were stationed at a suburban fire station. A state trooper arrived at the fire station with a 72-year-old male in the squad car. The officer had stopped the elderly gentleman earlier on suspicion of driving while intoxicated. In fact, the driver was observed to have been swerving and had sideswiped another vehicle. Prior to arrival at the fire station, the officer had taken the individual to a police substation and where he tested negative for alcohol. Apparently, a police drug recognition expert also evaluated the man and concluded that it was unlikely any drugs were implicated in the erratic driving.

The police officer reported to the ambulance and fire crew that he had noted the patient had experienced increasing difficulty speaking while being transported to the substation earlier. While at the substation, the patient s son was contacted, and an initial plan was made to meet the son at the patient s vehicle and leave the gentleman in the care of the son. However, the officer changed his mind while en route to the vehicle and brought the patient to the fire station for a medical clearance.

After the officer and patient arrived at the fire station, the EMS crew there apparently evaluated the gentleman. The patient told the staff that, for the past week, he had been experiencing left-sided weakness with episodes of numbness and uncoordinated movement.

Mentation was reported to be normal and all if his neuros were intact with no noted weakness or deficits. Vital signs: Blood pressure 158/82; pulse 78 and regular; respiratory rate 20. The blood glucose was 70.

Despite the report of normal neuros, the crew later revealed that they had noted a facial droop. At the time, the droop was attributed to the remote history of Bell s Palsy that the patient had noted.

The patient was allegedly advised that the symptoms he was experiencing might be caused by transient ischemic attacks (TIAs) or mini strokes and that they could be a precursor to a more serious problem. He was also allegedly advised that he needed to see a doctor ASAP. The crew claimed that they offered to transport him, but he declined.

At this point, the patient s son arrived at the fire station. The son either did not see a reason to have the patient taken to the hospital by ambulance, or was unable to convince the patient to be transported. The son told the crew that both his sister and wife were nurses implying that they would use their judgment about the need for immediate medical care. The son also expressed that the patient s previously noted facial droop and speech were normal for him.

The crew claimed they, once again, advised the patient of the risks of not being evaluated by a doctor. They reiterated their desire to take the patient to an emergency department and to call 911 if symptoms recurred. The patient then departed the fire station with the son.

All of this scenario may represent a risky, but fairly common, refusal except for one thing: No patient care report (PCR), or trip report, was ever completed for this actual case. All of the history and report of the encounter with the patient outlined above was generated from later incident reports the crew wrote in response to a complaint. All descriptions of the history and physical assessment were obtained later when the crew knew that there was an issue over the failure to complete a PCR. Therefore, it s entirely possible that the some of their recollection recorded in the incident reports was faulty, if not completely biased in support of themselves. In any event, an incident report would not carry the weight of a timely and properly completed PCR with an appropriate refusal in response to either a complaint or medical/legal lawsuit.

What was likely the cause of this patient s symptoms? Without a doubt, the patient s presentation strongly suggested unstable cerebral vascular disease. The paramedic s suspicion listed in the incident report of TIA symptomatology was very likely correct. Indeed some researchers place the risk of a major, completed stroke in patients such as this one at over 25 percent in the first three to four weeks after symptoms are first noted. Although we don t have any definite follow-up in this case, we re not aware that this patient developed a completed stroke in the first few weeks after this encounter.

How was it that a PCR was not completed in this case? Each of the two crewmembers claimed that they knew a PCR needed to be completed for this case. They never attempted to claim that this was a no patient contact situation. But each of the two primary providers thought that the other was going to write up the chart. Interestingly, both crewmembers signed the electronic chart template on the notebook computer, even though no documentation was ever placed into the record.

Both providers claimed that the facts outlined in the incident report were accurate as written. If that was the case, enough assessment was likely obtained to produce a fairly strong PCR. Unfortunately, the PCR was never started or finished.

Because the primary crew was composed of an EMT-B and a paramedic, the paramedic was ultimately held responsible for not ensuring that either he or the EMT completed the PCR. The paramedic is, in fact, the captain of the ship.

Refusals and no patient contact situations are very high-risk situations for patients, providers, agencies and medical directors. Obviously, the safest course from a liability standpoint in EMS is to transport all patients seeking prehospital evaluation. That, of course, is not possible. Some patients legitimately do not want to go to the hospital or need to.

As a general rule, any reasonable contact with a patient (talking with them, family or bystanders; examining them; reviewing assessment results from other providers, etc.) should exclude the claim of no patient contact. In short, no patient contact should mean exactly that: The crew had no patient contact at all.

Any other type of contact in a patient refusing to be transported should be considered a refusal. As such, a systematic evaluation needs to be carried out and documented on a PCR.

Specifically, the patient must meet the appropriate age to be legally eligible to refuse (18 years old); otherwise a legal guardian will be necessary to complete the refusal process. Most importantly, the patient or legal guardian must have sufficient capacity to understand the risks of refusing transport.

Capacity is a non-legal standard that physicians may use to qualify a patient s ability to understand what they re being told and provide consent. Initially, the presence or absence of developmental delay should be assessed by the EMS crew. Then the patient should be quickly screened for any obvious medical or traumatic conditions that may be expected to impair judgment (e.g., a head injury). Finally, the influence of drugs or alcohol should be considered. Documentation of stable vital signs and oxygen saturation helps substantiate a picture of reasonable mental capacity.

If none of these potentially mind-altering factors appear present, then EMS providers should explain to the patient the risks of refusal and give actual examples of deterioration that may well include death. Ideally, printed warning instructions related to their clinical presentation should be given to the patient. Providers should ensure that the patient is being offered the opportunity for transport and that if they choose against it, they may and should call 9-1-1 again if needed. At some point, a signature from the patient or legal guardian indicating they received EMS instructions should be obtained.

Finally, providers should contact medical control to review the case with the responding physician. Prehospital providers can assess a patient for capacity and advise online medical control of their opinion, but by law the declaration must be made by a physician. This step helps protect the patient and the paramedic and also fosters discussion and authorization with the doctor. Occasionally, the physician will be uncomfortable enough with the situation that a refusal may be denied, even though the prehospital crew thinks the refusal is safe. Sometimes, a conversation between the patient and medical control may convince a reluctant patient to accept ambulance transport.

What can we in EMS learn from this case?

  • Appreciate that patients with TIAs have unstable angina of the brain and may very likely go on to a major stroke in a short period of time.
  • Understand that refusals and no patient contacts are a high-risk situation in EMS.
  • Realize that mental capacity, and its proper assessment, is critical to establish before a refusal is accepted.
  • Properly warn and instruct patients with good mental capacity about the potential dangers of their clinical condition before continuing in the refusal process.
  • Always contact medical control and document it. Don t hesitate to seek the physician s advice, counsel and assistance, especially in muddy circumstances involving a refusal.
  • Limit no patient contact cases to actual no patient contacts.
  • Always fully document the refusal encounter in your agency s patient chart (PCR) using the general principles outlined in this discussion.

Editor s note: For more on the legal aspects of patient refusals, read Patient Refusal: What to do when medical treatment & transport are rejected in May 2006 JEMS.