Convincing a patient to be transported

[DrParasite]

I guess you guys are more dedicated than me.... I usually give up after 20 minutes. If they are alert and oriented, and nothing I say or do will change their mind, and they understand what is going on, then it's "please sign here, and if when you start feeling worse, call 911 and we will take you to the hospital." People have the right to make stupid decisions about their health, and even if I don't agree with them, they have the right to decide what happens.

now if they are disoriented, do not understand what is happening, or in other way can't make their own decisions, then we can get a supervisor and law enforcement involved to take them against their will.

Although, I can't wait for the day when I have a patient having a stemi, who won't consent to go to the hospital, and I can sit on the couch next to him, grab the remote and say "what are we watching? I'm going to wait here until your heart stops or you stop breathing, and then take you to the ER. i'm an hourly employee, so I'm in no rush. do you like comedy center?"

 

[rmena]

Screw that....principle of autonomy....if they don't want to go they can call us back when they do....sign here. Meeting criteria of course (I.e. Non suicidal, AO, etc.)

 

[Tigger]

I've spent over an hour on scene working with some new-onset dementia patients. I'd rather do that than have PD come over and put them on a hold and then deal with a "fight."

 

[Meursault]

I'm imagining hepatic encephalopathy. Apart from some drug users, these are some of the hardest people to reason with I have ever encountered. They seem to maintain their strength and dexterity even while being absolutely incoherent and unable to care for themselves. It's hard on the family as these are often people who are otherwise fairly reasonable and they can't imagine what is happening to them.

Yeah, the longest I've spent on scene for this (over an hour) was a woman with end-stage liver disease. A bit out of it, but speaking full sentences and completely adamant she wasn't going to the hospital for no reason she could articulate. We basically followed her around the house helping her walk and slowly wearing her down, with occasional non-helpful interludes from family. I can't remember all of it, but I don't think we actually convinced her so much as exhausted her. You know it's bad when there's a family member wondering why we aren't just dragging her out.

I let them "kick their own ***", so to speak If a patient is actually in distress or appears to be ill, I don't ride the idiot train and preach doom I simply ask them to demonstrate that they can take care of themselves. When they fail, I let them talk themselves into going.

Shortest AMA discussion: "No, I'm fine. Just help me up."
"Well, let's see." *pt's nearly-flaccid left leg goes out and he pitches sideways*
"Just put me in bed and it'll go away."
(possibly with a bit too much emphasis) "How do you know that?!"
"Alright, let's go." Wife: "Thank God."

 

[Amelia]

On my medic ride time, we spent like 20 minutes trying to convince a guy with a big STEMI to go. I was showing him the 12 lead like, "see these big upward deflections? They're called tombstones. Why do you suppose they're called that?"

Eventually he decided to have a family member drive him to the ED (we told him to go to a cath lab hospital). Maybe 30 minutes after we leave, we're called to the local ED for emergent transfer of a patient to PCI facility...

I love how strongly honest you guys are. Is this across the board? I certainly hope so.

 

[Handsome Robb]

Do VA hospitals receive ambulance patients / do they have emergency rooms? My understanding was that VA patients are seen in a standard ER than transfered to VA hospital if needed.

Our VA has an ER. We have to call, make sure they're a registered patient there then speak with the ER Physician who will either accept the PT or divert us to the hospital of their choosing or the TC if indicated.

Only catch is when the VA ERP gives us orders we have to hang up and call one of the "regular" ERs and talk to a doctor there to actually get orders since we can only take orders from base hospitals, which is every hospital in the area besides the VA.

 

[RedAirplane]

If they have an ER, don't they have to accept any patient that shows up? Isn't that some sort of federal law?

Like Kaiser has to stabilize uninsured patients before transferring them to another facility? And how apparently adults can walk into the Children's Hospital ER and be seen?

 

[Handsome Robb]

Yes they are technically required to however if we're calling we're not on their property so EMTALA doesn't apply in that case.

If someone were to stumble up to their ER with a GSW they'd have to treat them but you bet your *** we'd be requested as a lights and sirens transfer as soon as they figured out what was happening.

The other hospitals here are larger and more accessible area wise (lots of 1 way streets around the VA so it's a total pain in the *** to actually get to them) so they don't get many walk ups. At least not that I'm aware of.

 

[RedAirplane]

For trauma presenting at a small local ER, do they call 911 EMS or some IFT contracted ALS company?

If you dig up my thread history you'll see I was on a ride along where we went to do a CCT for a STEMI to go to an appropriate hospital. We didn't respond L&S and the nurse took his leisurely time to show up, while there were city ALS units sitting around doing nothing. Yet above it sounds like a STEMI needed 911 ALS L&S?

(Sorry, I know this is a huge digression.)

 

[Handsome Robb]

We are the sole ambulance provider in our county. Our contract with the county is written so no other services can come in and start operations unless we miss compliance whither espouse times 2 months in a row. Our contract was just renewed last year and is a 26 year contract, we're a private service operating under a public utility model. Kinda like a combination of a private and a government third service minus us being county employees, getting a county retirement and being sworn in. It's a very convoluted system. We doll the 911, IFT and SCTs in the county that covers ~6,000 square miles and has a total population of about 750,000. There is one little town that has an ALS transporting FD because the volume there is so low that my agency doesn't want to cover it because they'd require two ambulances in the area and it just wouldn't be profitable to cover it. They also existed before we came around.

Lights and sirens really don't save as much time as you think and that short amount of time saved rarely actually makes a difference. We have two types of transfers. Scheduled and unscheduled. Unscheduled transfers, lights and sirens or not, are treated as priority 1 calls so the nearest unit goes and cannot be diverted. When we're dispatched to those transfers (called a priority 99) they tell us either with or without lights and sirens depending on what the sending doctor requests. The VA and TC are literally 0.9 miles apart so we rarely transport their transfers lights and sirens because it doesn't make any more than 15-20 seconds of difference. A while back I was on scene of a scheduled transfer there and they requested a unit lights and sirens for a transfer. We left at the exact same time, they went emergent, we didn't and I was sitting in the entrance to the ambulance bay at the TC waiting for them to back into their spot so we could back into ours.

The reason the company you were riding with went and not an ALS 911 unit is because the agency you were with has a contract with the sending facility so that facility has to use that agency for transport. More than likely at least.

Depending on the Physician at the sending facility here we get requested lifts and sirens more or less. With some docs it's really common for us to respond code and transport routine, sometimes even with an ILS Attendant rather than the Paramedic. Other docs rarely request us lights and sirens and it's happened more than once that we respond routine and transport emergent. A lot of that has to do with crew comfort too. Our average experience for medics right now is 1-1.5 years, a lot of the newer medics transport a lot of patients emergently who definitely don't need it. Then we also have other crews, mostly FTOs or the few medics with a lot of experience who get train wrecks of patients who are vented and on more than one drop of the few that we can take and transport routine.

 

[Handsome Robb]

I guess you guys are more dedicated than me.... I usually give up after 20 minutes. If they are alert and oriented, and nothing I say or do will change their mind, and they understand what is going on, then it's "please sign here, and if when you start feeling worse, call 911 and we will take you to the hospital." People have the right to make stupid decisions about their health, and even if I don't agree with them, they have the right to decide what happens.

now if they are disoriented, do not understand what is happening, or in other way can't make their own decisions, then we can get a supervisor and law enforcement involved to take them against their will.

Although, I can't wait for the day when I have a patient having a stemi, who won't consent to go to the hospital, and I can sit on the couch next to him, grab the remote and say "what are we watching? I'm going to wait here until your heart stops or you stop breathing, and then take you to the ER. i'm an hourly employee, so I'm in no rush. do you like comedy center?"

Sounds like we've got a similar thought process. I rarely spend a ton of time trying to convince someone they need to go. If they really, really need to go I'll spend more time for the simple fact that if it goes sideways after we leave, the patient has a bad outcome and I end up in court it's easier to defend leaving them there if I was on scene for a. Longer than normal period of time showing that I truly did attempt to persuade them.

With that said you're exactly right, people have every right to make decisions about their healthcare whether it's a good or bad decision and we've got no right to force them to do something they don't want to do.

We had an interesting discussion the other day about a theoretical STEMI patient who adamantly refused to go, acknowledged that they may die and stated that "if it's my time it's my time." Can you actually legally wait outside for them to crump, come back in and work them? Sure at that point they can't make decisions however prior to that when they were capable of making decisions they made it very clear they didn't want treatment or help so are you actually legally allowed to work that patient and transport them to the hospital?

Everyone think on that for a minute and let me know what you think. I might just have to make a thread about this one...

 

[Clare]

I can't really think of a particular patient Roughly, our average on-scene time is about 20 to 30 minutes.

If we firmly recommend the patient go somewhere (be it their GP, A&M clinic, ED, have the District Nurses come round etc) most people are pretty good about it. Yes, there are a few people who don't want to for whatever reason but if they are really that crook then I'd say the majority can be convinced. However, if they truly don't want it then they are welcome to make an informed choice to not do so and that's fine. Never try to go against the patient's right to do so.

In the event ambulance personnel believe the patient should be transported to ED but the patient doesn't to then, depending where you are and what is reasonable, a reasonable medium can often be found in referring them to their GP or an A&M clinic or if they have somebody based in the community who knows them well such as the District Nurses or Community Health Worker, get them involved and either to come round or whatever.

 

[RocketMedic]

I just let Mother Nature take its course, the Volcano Gods tend to enjoy it better when their sacrifices are willing.

 

[Akulahawk]

For trauma presenting at a small local ER, do they call 911 EMS or some IFT contracted ALS company?

If you dig up my thread history you'll see I was on a ride along where we went to do a CCT for a STEMI to go to an appropriate hospital. We didn't respond L&S and the nurse took his leisurely time to show up, while there were city ALS units sitting around doing nothing. Yet above it sounds like a STEMI needed 911 ALS L&S?

(Sorry, I know this is a huge digression.)

I work at such an ER... and most of our traumas are flown out from the scene because none of the hospitals in the area are trauma centers. For the few traumas that we do get, if they do meet criteria to fly from the scene, we arrange for an emergent transfer out by air or ground. This policy also has the unfortunate result of us being less efficient in initial assessment and stabilization of trauma patients than we could be.

 

[Akulahawk]

I have used similar "prove to me that you're OK" lines in the past... One of which is "I need you to answer a few questions and if you get them all correct, I'll get out of your hair. You fail one and we take a ride. Deal?" The usual end result is that the patient goes to the hospital willingly because of our agreement as they prove to themselves they need to be checked out.

 

[ZombieEMT]

I generally do not stay longer than 20-30 minutes. Realistically, if you have been on scene that long and they are still refusing, chances are they probably are not going to change their mind. Ultimately, if the patient is conscious and alert, they have a right to refuse, even if they are going to die as a result. You can explain the full risks, and all of your concerns in that time period. The option always exists to call 911 again.

I also like to see the big picture on things. If the patient really does not want to go, there is no point in keeping the ambulance tied up until they change their mind or you give up. You still have an obligation to the rest of your coverage area, especially if you are the only ambulance. What if someone else needs help and wants help. Do we stand around and try to talk someone into going who in the end still chooses not to go?

The longest that I have ever been on scene with a patient was a police incident. I mostly blame the police on the issue, but in the end it was about an hour. The patient was drunk and had a head injury. We were trying to get him to go but he was uncooperative and combative, the police did not help the situation. At one point, we put out an all call to cover assignment, best way as a supervisor I thought to handle the call.