# Refusing to transport???



## MasterIntubator (Mar 5, 2012)

http://now.msn.com/now/0305-amputee-lawsuit-settlement.aspx

".......the paramedics who answered her 911 call wouldn't take her back to the ER...."

Soooo as I read this story, as well as a few others... they lead to the fact that FDNY medics did not transport her when she requested it.  The city paid 8 mil in the settlement.  What a sucky situation.

Anyone have any insight on this?  The stories seem somewhat vague..


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## MedicBrew (Mar 5, 2012)

If the story is true as reads, then I’d say she didn’t get enough. 

Lab should have caught the infection. 

As far as refusing to transport, that is considered criminal negligence. As a medic and public servant we have a duty to act, regardless if it’s a gomer or not. 

There's always 2 sides to every story though.

Wow, what a black eye for FDNY.


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## Shishkabob (Mar 5, 2012)

I don't see the culpability of the EMS system at all.  Story even says her boyfriend took her.  Unless the time between EMS refusal and BF transport was a lengthy time, nothing EMS could have done (transporting or otherwise) would have made a difference. And if it WAS that lengthy of a time, again... issue falls on them.

Crappy situation... but not EMS fault.  Transport is not a right.  This sets a bad precedent legally.




Part of negligence is proving cause and effect... I'd like to see how her lawyer 'proved' EMS not transporting had a detrimental effect above and beyond POV transport, and how if she would have been transported by EMS there would have been a different outcome.


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## MedicBrew (Mar 5, 2012)

Linuss said:


> Crappy situation... but not EMS fault.  Transport is not a right.



North of the Red River it is.

You call, we haul PEROID. 

You don't, then your looking for a new career.


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## Shishkabob (Mar 5, 2012)

MedicBrew said:


> North of the Red River it is.
> 
> You call, we haul PEROID.
> 
> You don't, then your looking for a new career.



Policy =/= right.  Just because your agency says you 'have to', doesn't mean it's a law, federal, state, local or otherwise.


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## Hellsbells (Mar 5, 2012)

Any one have other links? This story is way too brief to get all the details.


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## Shishkabob (Mar 5, 2012)

After reading the expanded article, they waited 24 hours to take her.

Serious enough to call 911, but not serious enough to drive yourself?




But it's also a settlement and not a lawsuit win as the original article leads to believe.


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## MedicBrew (Mar 5, 2012)

Linuss said:


> Policy =/= right.  Just because your agency says you 'have to', doesn't mean it's a law, federal, state, local or otherwise.




Forgive me, I can't find the exact statute. OK State Statute title 63,ss 63-1-2502-24-a covers transporting to the facility of the patients choice. 

Basically states that if a patient requests EMS for treatment and transport, then said individual has the right to medical care. Regardless if you find it medically necessary. 

Your definition of an actual emergency defers greatly than that of most of the public. (Should say yours and mine)

That’s for a Board lic. Physician to decide, not us. According to OSDH.

But yes, it’s company policy as well. Not that I agree with it, just the way it is.


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## Shishkabob (Mar 5, 2012)

Having read that statute, no.  

To be clear, the statute says the it is up to the individual / regional agency to decide on transport protocols, but that they should include allowing the patient to choose in 'non-emergency, routine transports' (arguably non-911).  However, in urgent, non-life threatening situations, is to be taken to the closest appropriate facility, unless system coverage is able to facilitate a further transport.  Life threatening emergencies are to be transported to the closest apprpirate.


This A) Does not say transport is a right, and that anyone requesting it get it, and B ) says the patient gets a choice, so far as it is compliant with the local agencies guidelines.






Several agencies across the US, mine included, do have situations where transport can, and is, refused to those that request it.  To my knowledge, most require physician approval.  Clearly, so far as these agencies and their lawyers are concerned, it's legal.


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## MedicBrew (Mar 5, 2012)

MedicBrew said:


> Forgive me, I can't find the exact statute. OK State Statute title 63,ss 63-1-2502-24-a covers transporting to the facility of the patients choice. Basically states that if a patient requests EMS for treatment and transport, then said individual has the right to medical care. Regardless if you find it medically necessary.
> 
> Your definition of an actual emergency defers greatly than that of most of the public. (Should say yours and mine)
> 
> ...



Give me a bit, I'll keep digging. Just left shift.


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## Aidey (Mar 5, 2012)

I'm having a hard time finding any news coverage older than the articles about this settlement, so there is a lot of missing information. 

I'm with Linuss. Transport is not a right. Unfortunately because of a variety of reasons EMS systems are still held liable if they don't transport, even if there is zero treatment that would be done en route and the patient would end up in triage anyway*. I do acknowledge though that there is a difference between refusing to transport someone who has the means gain medical care another way and giving bad/wrong advice. 

*At the local hospitals if you come in by ambulance for the same problem you were seen at the hospital for yesterday you buy an automatic seat in triage unless all the ED beds are open, or you are very obviously sick.


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## MedicBrew (Mar 5, 2012)

Aidey said:


> I'm with Linuss. Transport is not a right. Unfortunately because of a variety of reasons EMS systems are still held liable if they don't transport, even if there is zero treatment that would be done en route and the patient would end up in triage anyway*. I do acknowledge though that there is a difference between refusing to transport someone who has the means gain medical care another way and giving bad/wrong advice.
> 
> *At the local hospitals if you come in by ambulance for the same problem you were seen at the hospital for yesterday you buy an automatic seat in triage unless all the ED beds are open, or you are very obviously sick.



Too slippery a slope….

By the time you’re done talking with the patient and finishing paperwork, you could’ve been to the hospital. That’s even out here in the sticks. 

Losing only a bit of diesel in the process, and side stepping the liability (and media coverage) completely.  

Just how I see it. Seems that philosophy would be like opening Pandora’s box.


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## ffemt8978 (Mar 5, 2012)

MedicBrew said:


> Too slippery a slope….
> 
> By the time you’re done talking with the patient and finishing paperwork, you could’ve been to the hospital. That’s even out here in the sticks.
> 
> ...


You're walking a pinnacle there, with a slippery slope on both sides.

Don't transport = liability, bad media for not transporting
Do transport = system abuse, crews not available when needed, increased costs for patient, bad media for not being immediately available, etc...


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## Shishkabob (Mar 5, 2012)

MedicBrew said:


> Too slippery a slope….
> 
> By the time you’re done talking with the patient and finishing paperwork, you could’ve been to the hospital. That’s even out here in the sticks.
> 
> ...


And that's how many of the dinosaurs see it, but that doesn't make it right.  You then cost the ER a bed, hospital wasted personnel time, insurance companies wasted money, Medicare and Medicaid wasted reimbursement, and the average person higher taxes and insurance premiums.


Hence why some of the most progressive agencies are doing at home care and/or provider initiated refusals... and actually getting good publicity from it and its savings for the general public, both in money and available resources for more legit concerns.


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## Handsome Robb (Mar 5, 2012)

Haven't a few members on here worked at agencies that have refusal of transport protocols for their providers?


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## ffemt8978 (Mar 5, 2012)

NVRob said:


> Haven't a few members on here worked at agencies that have refusal of transport protocols for their providers?



We got one, and we're a volly agency.


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## Aidey (Mar 5, 2012)

Exactly. Not everyone needs an ED. Most people have 3 levels of care to chose from. Personal GP, urgent care center, and ER. Tons of the people we see are more appropriate for the personal GP or urgent care. Cold/flu symptoms, simple wound care/stitches, and x-rays of non-deformed injuries are 3 very common reasons we get called that can be treated more quickly and cheaply at an urgent care center.


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## Shishkabob (Mar 5, 2012)

MedicBrew said:


> By the time you’re done talking with the patient and finishing paperwork, you could’ve been to the hospital. That’s even out here in the sticks.



Plus, you know what can be done while talking to the patient?  EDUCATION!  Educate them on their concern.  Then you probably save yourself repeated calls in the future, and actually HELP your patient.




NVRob said:


> Haven't a few members on here worked at agencies that have refusal of transport protocols for their providers?



Currently do.


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## Handsome Robb (Mar 5, 2012)

Linuss said:


> Currently do.



You should write my MD a letter talking advocating it.   Pretty please. 

We've been trying to get something going but I don't think it's going to happen unless we get a new, more aggressive/progressive MD.


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## ffemt8978 (Mar 5, 2012)

NVRob said:


> You should write my MD a letter talking advocating it.   Pretty please.
> 
> We've been trying to get something going but I don't think it's going to happen unless we get a new, more aggressive/progressive MD.



Are you sure you want Linuss writing your MD?


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## Handsome Robb (Mar 5, 2012)

ffemt8978 said:


> Are you sure you want Linuss writing your MD?



Meh, why not? Is there something I don't know? Did I make an *** of myself and make Linuss not like me? :unsure:


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## ffemt8978 (Mar 5, 2012)

NVRob said:


> Meh, why not? Is there something I don't know? Did I make an *** of myself and make Linuss not like me? :unsure:



Not that I'm aware of...I just wasn't sure Linuss would be the most credible source of info.  :rofl:


I kid.  Maybe a MD to MD letter would carry more weight than an out of state medic to MD letter.


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## Shishkabob (Mar 5, 2012)

I was actually going to recommend your MD speak to my MD (well.. DO  ) as he has the specifics I don't.  I just know we do it.

But NOOOOO... ffemt has to steal my thunder, insult me and beat me to it!  I see how it is!


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## Melclin (Mar 6, 2012)

NVRob said:


> Haven't a few members on here worked at agencies that have refusal of transport protocols for their providers?



While we technically cant refuse to take people to hospital because of wording in the ambulance act (as is my understanding at least), we certainly don't take people to hospital if its not necessary.

I think the language is all wrong in this kind of discussion. 

As I've said before, some decent research done here has suggested that people in our system call 000, not because they think they are having a medical emergency or that they need to go to hospital, but because they lose the ability to cope with a situation that is healthcare related. We turn up and either we cope with the situation or we help them too do it themselves. Taking a person to hospital is one option but its not predominantly why people call. Often at the end of a discussion with a pt they ask, "So what do ya reckon? Do I need to go to hospital?" I summarise their situation, give them their options and give them my own recommendation and help them to make a decision. 

All the language used here is so adversarial. I'd like to think that I discuss the need for hospital with pts and we come to a consensus about what is best for them, generally both we and the pt are happy.

An exception might be those problems callers who don't need us or an ED but call 3 times a day. They go every time for various logistical reasons. But then how they are dealt with in the long term, things like how and when and on what priority they will get an ambulance in the future is managed at a higher level. Psych and ?OD pts are almost always transported too, on account of the complex nature of psych issues and the need for more expert and in depth assessment. Most kids go as well, but that is a personal thing because I don't see enough kids, nor do I have sufficient paeds expertise to feel comfortable making those decisions.


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## bw2529 (Mar 6, 2012)

I don't know at what level the rule comes from, but at my volunteer agency in NYS (MLREMS), you call: we haul. Patients can refuse transport, in most cases, but if they want to go we have to take them. It may be possible to get medical control to direct us otherwise, but I've never heard of that happening. Our techs always tell people "Our position is always going to be if you had a problem that you felt warranted calling 9-1-1, you should go to the hospital." In order to sign someone off we have to go through a whole spiel about how the patient could die a horrible terrible death if they don't let us transport them.

My agency pays by the transport, and normally only bills if we transport, so in most cases everyone wants a transport to happen (the pt., the crew, and the agency). I feel very fortunate when I say that we don't really have an issue with resources. We have a lot of volunteers, and three well stocked rigs (most of the time only one is out at a time).


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## MedicBrew (Mar 6, 2012)

Linuss said:


> And that's how many of the dinosaurs see it,



Dang I'm not even 40 yet



Linuss said:


> Plus, you know what can be done while talking to the patient?  EDUCATION!  Educate them on their concern.  Then you probably save yourself repeated calls in the future, and actually HELP your patient.



Seems a little presumptuous to draw that conclusion from a simple forum post?  


As far as our earlier discussion, as promised I did further research and ……… are you ready???

Linuss you are correct!!                  I grovel at your feet.   

I contacted our area State rep and spoke with him about this topic. His reply was that it is covered under the “Duty to Act” clause.  There is no direct statue that precludes provider initiated refusals, but he did advise against for similar reasons I stated prior. 

So, 

When I’m wrong, I say I’m wrong. 

I stand corrected sir.


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## Tigger (Mar 6, 2012)

bw2529 said:


> My agency pays by the transport, and normally only bills if we transport, so in most cases everyone wants a transport to happen (the pt., the crew, and the agency). I feel very fortunate when I say that we don't really have an issue with resources. We have a lot of volunteers, and three well stocked rigs (most of the time only one is out at a time).


Transporting someone because it gives an agency the right to bill is terrible reasoning for transporting everyone. Fear of litigation is at least something that is often brought about by lawyers and not the agency itself. EMS agencies are charged with serving the public, not taking everyone who calls to the hospital. It is a complete breach of the citizens' trust to transport everyone for the sake of what amounts to fundraising, sadly this unfolds every day all over the place.


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## ShannahQuilts (Mar 6, 2012)

It would make a difference in my decision-making if I felt that by giving someone an "unneeded" transport, I would be potentially denying help to someone else.

In a situation with 3 rigs and only one out at a time, usually, I would be a lot more keen to transport than in a situation where resources were a lot more scarce.

I think that, in situations where you have people who don't know what they are doing making requests (the patients, usually), the best you can do is use your judgment, follow any rules you need to, and just hope you don't wind up on the wrong side of a lawsuit.

I do wonder, though, if it sounds a lot more scary than it really is.  I wonder what percentage of requested transports (whether the patient is transported or not) result in a lawsuit.  Isn't that pretty vanishingly rare?


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## Tigger (Mar 7, 2012)

ShannahQuilts said:


> It would make a difference in my decision-making if I felt that by giving someone an "unneeded" transport, I would be potentially denying help to someone else.
> 
> In a situation with 3 rigs and only one out at a time, usually, I would be a lot more keen to transport than in a situation where resources were a lot more scarce.
> 
> ...



It should not be the field provider's job to determine the allocation of ambulances to a region. You have one patient and that's the one in front of you. Potential patients don't count, you provide the best care for the patient that presently exists. If you think they need to go the hospital because that's how they get the best care, then they go to the hospital. If taking them to the hospital is not getting them the best care, then you don't take them. It's that simple.


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## bw2529 (Mar 7, 2012)

Tigger said:


> Transporting someone because it gives an agency the right to bill is terrible reasoning for transporting everyone. Fear of litigation is at least something that is often brought about by lawyers and not the agency itself. EMS agencies are charged with serving the public, not taking everyone who calls to the hospital. It is a complete breach of the citizens' trust to transport everyone for the sake of what amounts to fundraising, sadly this unfolds every day all over the place.



We don't force anyone who doesn't want to go to go.


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## Shishkabob (Mar 7, 2012)

bw2529 said:


> We don't force anyone who doesn't want to go to go.



Okay... but how many people go because they think that since EMS was called, they have to?

How many goes because they think that going by EMS is the quickest way in to the ER?

How many goes because they think EMS is registration for the hospital, and that to be seen, you have to go by ambulance?




Do you educate the people, or do you say "Hop on, what hospital do you want to go to?"

I've noticed something... the way you phrase your transporting of them either increases or decreases the likelihood of transport.  My partner, who's been doing this for 20 years, says "What hospital are we taking you to?"  I ask "Would you like us to take you to the hospital?"  I get so many more people refusing transport then he does.  When you give someone the option, they will decide for themselves, rather then thinking that they HAVE to go.  When they realize that they DON'T have to go by you, they ask what their options are, and what you, the educated professional, thinks is best.


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## 46Young (Mar 7, 2012)

Linuss said:


> And that's how many of the dinosaurs see it, but that doesn't make it right.  You then cost the ER a bed, hospital wasted personnel time, insurance companies wasted money, Medicare and Medicaid wasted reimbursement, and the average person higher taxes and insurance premiums.
> 
> 
> Hence why some of the most progressive agencies are doing at home care and/or provider initiated refusals... and actually getting good publicity from it and its savings for the general public, both in money and available resources for more legit concerns.



My department has failed to see the benefit to provider initiated refusals, home care, triage over the phone by a nurse, etc. What I've been told is that we can curb the 911 volume by doing these things, but then that recduces our revenue. Same for the hospitals. They don't want to fund or initiate any of these measures as that will similarly reduce their revenue. I work in an affluent, predominately young county, so many of our residents have commercial insurance, and most of the remainder have Medicare.
Also, unless things have changed in the last 4+ years, when I worked in the NYC 911 system, we were legally required to transport anyone that requested it, no matter the reason. Not transporting someone could get us fired in a hurry. NYC providers are extremely litigation phobic, and will take the easy road to guard against any liability.

I know many of us are geeked up hearing about Advance Care Paramedics, provider initiated refusals and all, but this simply isn't a reality in many areas due to lack of vision by the powers that be.


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## 46Young (Mar 7, 2012)

Tigger said:


> Transporting someone because it gives an agency the right to bill is terrible reasoning for transporting everyone. Fear of litigation is at least something that is often brought about by lawyers and not the agency itself. EMS agencies are charged with serving the public, not taking everyone who calls to the hospital. It is a complete breach of the citizens' trust to transport everyone for the sake of what amounts to fundraising, sadly this unfolds every day all over the place.



Agreed, but how would you suggest I change the minds of my department and the area hospitals, whose priorities are protecting revenue and preventing lawsuits? How would this change be beneficial to them? They need a really good reason, or it will continue to be business as usual.


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## Sasha (Mar 7, 2012)

bw2529 said:


> We don't force anyone who doesn't want to go to go.



Not true! Psychs and demented patients!


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## 46Young (Mar 7, 2012)

Linuss said:


> Okay... but how many people go because they think that since EMS was called, they have to?
> 
> How many goes because they think that going by EMS is the quickest way in to the ER?
> 
> ...



When it appears early on that the pt will need an ambulance and the hospital, we will ask if they want to go to the hospital, so that we can move to the ambulance and begin any invasive therapies. Usually, if it's bullcrap, we can identify that pretty early on, and the question will instead be, "What would you like us to do for you?" Sometimes we can explain how an urgent care or private MD visit "or even a call to the local Pharmacist is more cost effective and appropriate for them." The problem is, department S.O.P.'s and our EMS manual mandate that we tell them we're always going to recommend transport (officially), no matter the situation. All this other stuff is explained off the record.


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## Tigger (Mar 7, 2012)

bw2529 said:


> We don't force anyone who doesn't want to go to go.


Well I should hope not, otherwise you'd be running afoul of those pesky kidnapping and false imprisonment laws. 

The public trusts you to decide for them whether or not they need to go to the hospital. Whether or not that trust is misplaced is an entirely different matter, but the point still stands. If someone is wishy washy on whether or not they want to go (remember it is _their_ choice most of the time), and you say "we'll take you to the ER for 'precautionary testing,'" when you really mean "we'll take you to the hospital and then bill you/your insurance," you are doing your patient a disservice. 



46Young said:


> Agreed, but how would you suggest I change the minds of my department and the area hospitals, whose priorities are protecting revenue and preventing lawsuits? How would this change be beneficial to them? They need a really good reason, or it will continue to be business as usual.


I'd be the first to admit that my argument is completely shredded by elementary economic theory. It will not protect revenue, and it's possible that an increase in litigation ensues. It's business as usual at 99% of EMS agencies nationwide. When healthcare is a for-profit system, it only makes sense to see as many patients as possible, even when the patients should not be patients in the first place. It's a universal theme. Those places that are "progressive" are likely taking a loss by being so. Reducing overall system costs does not generally translate into profit.


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## 46Young (Mar 8, 2012)

Tigger said:


> I'd be the first to admit that my argument is completely shredded by elementary economic theory. It will not protect revenue, and it's possible that an increase in litigation ensues. It's business as usual at 99% of EMS agencies nationwide. When healthcare is a for-profit system, it only makes sense to see as many patients as possible, even when the patients should not be patients in the first place. It's a universal theme. Those places that are "progressive" are likely taking a loss by being so. Reducing overall system costs does not generally translate into profit.



The only entities that would benefit financially right away would be the insurance companies, and Medicare/Medicaid. I don't see them funding or otherwise subsidizing Advance Care Paramedic programs, or anything else mentioned earlier for that matter.

Perhaps in a densely populated area with many patients being uninsured or at most on Medicaid, the municipality and the hospitals could see a benefit by not treating some of these patients, since these are uncompensated/undercompensated billing events.


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## ShannahQuilts (Mar 8, 2012)

Tigger said:


> It should not be the field provider's job to determine the allocation of ambulances to a region. You have one patient and that's the one in front of you. Potential patients don't count, you provide the best care for the patient that presently exists. If you think they need to go the hospital because that's how they get the best care, then they go to the hospital. If taking them to the hospital is not getting them the best care, then you don't take them. It's that simple.



I was thinking in terms of situations where it wasn't so clear cut.  I've read a lot of comments by experienced folks who seem to think that not every case is obviously either transport or don't.  

Sure, if someone clearly needs transport, I'd do whatever I could do to get them that transport.  I also know there are cases where it's a judgement call.  Or even an educated guess.


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