EMTs writing ALS refusals

AeroClinician

AeroClinician

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Isn't this a potential liability? Having someone with training that is less than the determinined level of care that was decided upon by a paramedic write an ALS report? I know of an als dept that routinely has emts write als refusals, syncopal episode, chest pain, diabetic. How can an emt know the ins and outs of the als assement that preceded the refusal and the specific info that needs to be in the report to properly document in a way to reduce the amount of possible liability.
 
At my full time job, the medics have to right every refusal, whether it was a simple thing, like checking someone's blood pressure because they just wanted to be sure it was ok, or something more serious.

At my old job, EMTs could do the refusals that fell within their scope of practice.

If I ever had an EMT write a refusal that I should be writing, I can guarantee there would be people I would have to answer to.
 
I have done them as an EMT before.....but only when I worked on a BLS unit and the call was WELL within my scope.
 
I have been around services that allowed EMT-Bs to write ALS refusals. You're right, its not right and will eventually bite someone on the ***. As an EMT, you're not trained to perform the proper ALS asssessment- therefore how could you document the pertinent positive/negatives you found about the pt? I have done it before as an EMT-B that was in paramedic school. Thank god that policy has been changed. Didnt feel it was right.
 
We currently dont write any refusals but that will be changing soon. Mostly anything that an EMT would take in they write the refusal for.

If the complaint was syncope, the medic will write it whether they did ALS or not. At least thats how I see it happening.
 
How about a known diabetic patient who's agitated but otherwise relatively alert upon arrival, the BLS crew gets their sugar back up, checks a new BGL, and gets a refusal?

ALS?
 
EpiEMS said:
How about a known diabetic patient who's agitated but otherwise relatively alert upon arrival, the BLS crew gets their sugar back up, checks a new BGL, and gets a refusal?

ALS?
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Not ALS. Although if the EMTs cannot check and document a FSBG then it becomes ALS in my opinion for the sake of thorough documentation.

If it's a complaint that cause me to do an assessment using an ALS tool (ie monitor) its my chart to write, transport or refusal.

If they have an ALS complaint (ie chest pressure/pain, shortness of breath, something like that) but they refuse any and all assessment, intervention and transport I'm still writing that chart. At the end of the day, and please don't take any offense to this all you EMTs out there, it "looks" better in court with a paramedic's name and signature on the chart.

EMTs writing ALS refusals sounds like a recipe for a lawsuit that ends badly for the company and potentially the EMT. Any "high risk" AMA shoulda have a paramedic writing the refusal. "High risks" is a term I use loosely.

I personally think we play with fire where I work allowing EMT-Is to attend and chart altered diabetics (transport or refusal) that we give D50 to for the simple fact that even though its well within their scope our "ALOC/Diabetic/GCS
 
EpiEMS said:
How about a known diabetic patient who's agitated but otherwise relatively alert upon arrival, the BLS crew gets their sugar back up, checks a new BGL, and gets a refusal?

ALS?
Click to expand...

ALS here simply because techs cant check a BGL. I still view it as ALS regardless, but I come from a system that still requires we call OLMC for a diabetic refusal :banghead:
 
Like you mean physically writing and signing the RMA? Our just writing out and they medic signs it? Don't have any problem with an EMT writing the RMA, it's the same thing regardless of treatment rendered
 
Robb said:
Not ALS. Although if the EMTs cannot check and document a FSBG then it becomes ALS in my opinion for the sake of thorough documentation.

If it's a complaint that cause me to do an assessment using an ALS tool (ie monitor) its my chart to write, transport or refusal.

If they have an ALS complaint (ie chest pressure/pain, shortness of breath, something like that) but they refuse any and all assessment, intervention and transport I'm still writing that chart. At the end of the day, and please don't take any offense to this all you EMTs out there, it "looks" better in court with a paramedic's name and signature on the chart.

EMTs writing ALS refusals sounds like a recipe for a lawsuit that ends badly for the company and potentially the EMT. Any "high risk" AMA shoulda have a paramedic writing the refusal. "High risks" is a term I use loosely.

I personally think we play with fire where I work allowing EMT-Is to attend and chart altered diabetics (transport or refusal) that we give D50 to for the simple fact that even though its well within their scope our "ALOC/Diabetic/GCS
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First things first. My medical director states in my protocols that if any medication is given. And I do many any including oxygen then online med control shall be contacted and every effort including baker acting the individual should be taken to transport. I see both sides of this argument.

Md side. I trust my ALS and BLS units under my license to make informed decisions and care enough about the pt to get then to definitive care

EMS I am competent and can make a judgement call on when a pt needs D50 or a peanut butter maple syrup sandwich. I have the personality and the likability to get a pt to do what is medically nessecary.

Comments and complaints are welcome
 
Robb said:
Not ALS. Although if the EMTs cannot check and document a FSBG then it becomes ALS in my opinion for the sake of thorough documentation.

If it's a complaint that cause me to do an assessment using an ALS tool (ie monitor) its my chart to write, transport or refusal.

If they have an ALS complaint (ie chest pressure/pain, shortness of breath, something like that) but they refuse any and all assessment, intervention and transport I'm still writing that chart. At the end of the day, and please don't take any offense to this all you EMTs out there, it "looks" better in court with a paramedic's name and signature on the chart.

EMTs writing ALS refusals sounds like a recipe for a lawsuit that ends badly for the company and potentially the EMT. Any "high risk" AMA shoulda have a paramedic writing the refusal. "High risks" is a term I use loosely.

I personally think we play with fire where I work allowing EMT-Is to attend and chart altered diabetics (transport or refusal) that we give D50 to for the simple fact that even though its well within their scope our "ALOC/Diabetic/GCS
Click to expand...

There was another paragraph in this post that disappeared apparently and I'm too lazy to retype it.

Spark notes: our aloc protocol says cardiac monitor and it's the only protocol we have standing orders to give D50.
 
I write lots of refusals but as was stated, only when they are within my scope of practice. If they receive any type of ALS treatment, its the medic's job to write the refusal
 
Since NJ has its own unique system of ALS response, any patient refusing transport and/or treatment has to sign 2 RMAs - one from the BLS agency and one from the ALS agency.
 
Robb said:
At the end of the day, and please don't take any offense to this all you EMTs out there, it "looks" better in court with a paramedic's name and signature on the chart.
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Let me let you in on a little secret: it doesn't look better, because a Paramedic, or an Emergency Medical Technician will look the same in the eyes of the court. They are both EMS professionals, and while you can argue that you have more education, the court will also weigh experience levels, years in the industry, and most importantly, how well and through the document is written. So you signing Robb, EMT-P, isn't going to look any better than Dr P, BS, EMT.
Robb said:
EMTs writing ALS refusals sounds like a recipe for a lawsuit that ends badly for the company and potentially the EMT. Any "high risk" AMA shoulda have a paramedic writing the refusal. "High risks" is a term I use loosely.
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please define writing ALS refusals.

has the paramedic assessed the patient, and they are refusing? have any interventions been given? Some places say any high risk AMA needs consultation with a supervisor, who is often no more educated than the field provider.
Trashtruck said:
Wow. NJ never ceases to amaze me!
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not sure why... it makes perfect sense to me. two separate agencies assessed the patient, and they are refusing care. both agencies get signed refusals. Can they turf the responsibility to the paramedic? probably, but it's better from a litigious standpoint to have your own copy of a refusal of service. I know when I was in NY we did this all the time, when the paramedic was coming from a different service.

I really don't understand the question. for me, the issue is were any ALS interventions given prior to the RMA. if so, than the medic should be writing and signing the chart. if it's just an assessment, and the patient doesn't need any ALS interventions, and the patient still wants to RMA, let the EMT write the chart.

and any EMT who can't do an assessment..... well, I can't even say that, because I hear horror stories about some of the EMTs on this forum....
 
If the patient is determined to be appropriate for ALS to assess, and an EMT is the one that does the determination, and the patient refuses prior to the paramedic arriving to do the assessment, I personally think that it is absolutely appropriate that the EMT be able to write the refusal.

If a paramedic has seen the patient and assess the patient, and the patient then refuses, that is when the EMT should not be allowed to write the refusal because it was not his or her patient that refused. If the paramedic has assessed the patient and determined that the patient is not ALS, rather can be transported by BLS, and the patient then refuses, then the EMT that initially assessed the patient or accepted the patient from the paramedic should be allowed to write the refusal in that case. In that particular case, the EMT should also retain the right to refuse the writing of referral and kick it back to the paramedic.

In that case, it would be because the patient falls within a BLS scope of practice but the turnover of care went from ALS to BLS followed by the refusal.
 
DrParasite said:
Let me let you in on a little secret: it doesn't look better, because a Paramedic, or an Emergency Medical Technician will look the same in the eyes of the court. They are both EMS professionals, and while you can argue that you have more education, the court will also weigh experience levels, years in the industry, and most importantly, how well and through the document is written. So you signing Robb, EMT-P, isn't going to look any better than Dr P, BS, EMT.
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I have a hard time believing this. Do you have a source proving this?
 
ALS call = ALS assessment = ALS refusal. There are exceptions, however. I think some of it depends of the amount of assessment done. Obviously disregards will be written by the EMT, there could also be a good case for letting them write calls in which the patient is denying any assessment.
 
If the patient is refusing any sort of vital sign assessment or transport at all, and the patient is alert, oriented, and is legally capable of making a refusal, then it doesn't matter what the complaint is or how the patient looks unless there is something obviously life threatening that would justify transporting the patient against their will (baker act).

At that point it doesn't matter if it is an EMT, a first responder, ALS, or a doctor filling out the form...the patient has a legal right to refuse treatment regardless of who or what or where or when...


If an assessment is carried out on scene and then the patient refuses transport, then again it does not matter, if a BLS assessment is carried out then BLS can fill out the refusal form. If an ALS assessment occurs (12 lead) then ALS writes the refusal. Doesn't matter if the patient is having chest pain, if you take their BP and its 180/100, they are having horrible pain, and are sweating like crazy, and you recommend that ALS come to scene and the patient refuses a 12 lead or a 3 lead and refuses transport then it still a BLS assessment and BLS can write the refusal.


In my opinion (and legally I believe) a patient is not a "ALS" patient until a ALS provider assesses or treats the patient. Whatever the highest level of provider has preformed an assessment is the highest level required for a refusal. Again assuming no obvious immediate life threatening injuries or illnesses and the patient is oriented and has the legal right to refuse...
 
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