Patient Education, Medicine Without a License, and You.

[Shishkabob]

We've all been there. A patient or their family asks "So what should we do?" More often than not, the typical response I've seen is "I can't answer that due to liability". Question is, is it really? Time and time again, I see providers go "You called for a reason", or something of that nature. For people that "refuse" transport, they ask what they should do, what OTC meds they should take. Providers are often worried about some legal thing that prevents them from answering something as simple as "If it was me, I'd take aspirin or another thing like it", for fear of "practicing medicine without a license".

How can we continue to progress as professionals if we can't answer those questions out of fear of litigation, getting in trouble at our work, or some other issue?


How are we to go about educating our patients if we can't answer simple questions like this? What are your agency's rules, if any, on answering questions like that? What do you personally do to educate people, either on their misuse of the system, or what OTC meds might help, or any other types of questions they may have for you, the healthcare professional?



My agency has some handouts we give for specific ailments, in English and Spanish, if patients 'refuse' transport, such as seatbelt bruises and airbag burns from MVCs, care after a hypoglycemic event, care for minor wounds, and others.


I'll admit I sometimes sidestep a straight answer with a "That puts me in a tough spot if anything goes wrong", but I've also said "If it was me or my family...".

 

[Aidey]

I received absolutely zero education on how to appropriately educate patients in medic school. I would love it if we had some sort of instruction besides "tell everyone to go to the hospital". I think there could be a lot of resistance to formalizing the education on patient teaching because there is still the strong mindset of transport, transport, transport.

I've had to do the same thing as you have. "I'm not a doctor, and I can't give out medical advice, but in theory there is a 24 hour Wallgreens 5 minutes away, and in theory they sell benadryl cream, which has instructions on the package for how to apply it properly."

 

[Medic29]

I received absolutely zero education on how to appropriately educate patients in medic school. I would love it if we had some sort of instruction besides "tell everyone to go to the hospital". I think there could be a lot of resistance to formalizing the education on patient teaching because there is still the strong mindset of transport, transport, transport.

I've had to do the same thing as you have. "I'm not a doctor, and I can't give out medical advice, but in theory there is a 24 hour Wallgreens 5 minutes away, and in theory they sell benadryl cream, which has instructions on the package for how to apply it properly."

Like he stated, why can't we just admit to them that we are not doctors but give advice anyways? Make sure to let them know that their doctor would know best and they should contact them or if the area you work in has a program like Ask-A-Nurse like we had in Iowa. A free service for people in such situations. Document what was stated and just COA. If the patient has signed refusal forms, doesn't that clear you of any liablility should you give any advice?

Also, if they're asking for OTC med recommendations you're not really playing doctor or medic when you answer them. imo even though you're in a healthcare professional role, you can't go a day without seeing a commercial on TV about OTC meds. Maybe say something along the lines of "your indegestion can be helped by using that pink creamy sh*t you can get at any store down the street". IDK to be honest I'm just throwing out a suggestion.

 

[Aidey]

She.

The problem is that we might be wrong. Sure anyone can walk into a store and buy OTC meds without any medical advice and if it was the wring med, oh well. We are seen as having some authority, even if we preface what we say with "I'm not a doctor". Refusal forms only protect you from so much, and I know home treatment advice isn't covered in our refusal language. It would be wonderful if we could give real advice, but I just don't see it happening anytime soon.

 

[Medic29]

She.

Sorry :blush:

 

[MS Medic]

On ocassion I will answer those types of questions by saying "I'm not allowed to give out medical advise but if it were me, this is what I would do..."

But with that said, time to let the burn out in me come out: It is not my job to give out free medical advice. The owner of my service does not get paid unless I haul them to the hospital and if he doesn't get paid then guess who else doesn't.

We are "Emergency Medical Services" not the community free clinic. If they are worried about their tummy hurting from reflux or their :censored: runny nose, then get in the car, on the bus, or whatever and go to the county health clinic and stand in line.

But by all means, if they want to go to the hospital for such things, then feel free to call me and I'll give them service with a smile. Of course, unless it is 3 in the morning, then it's sans the smile.

 

[systemet]

How can we continue to progress as professionals if we can't answer those questions out of fear of litigation, getting in trouble at our work, or some other issue?

I think this is a good question, and it's difficult to answer. In a lot of systems, right now, there's no incentive for providers to decline transport, or direct a patient to other resources. The system often doesn't make money if this happens, and then if you provide advice, there's a potential legal exposure, that will eventually cost money.

It's simpler for the average ambulance service to tell it's paramedics not to dispense any advice. For physician medical control, they're often working in the ER, and ultimately turning away patients represents a legal liability to them, or is going to cut down on the amount of ER traffic and how much they can bill.

I think this is partly a structural problem within the system, although medical tort law doesn't help.

How are we to go about educating our patients if we can't answer simple questions like this? What are your agency's rules, if any, on answering questions like that? What do you personally do to educate people, either on their misuse of the system, or what OTC meds might help, or any other types of questions they may have for you, the healthcare professional?

I've never been given specific rules as to "These are the situations in which you can give advice", or "This is the advice you should dispense". I was given a few paragraphs of information about the risks of thrombolysis that I could read to patients if they had concerns, but this wasn't mandatory to use.

I would echo an earlier poster, and say that I never received any specific instruction on patient education during my training. I'm also not sure whether the depth of my education would allow me to dispense decent advice to the right people. It just wasn't focused in that area.

 

[systemet]

Another point, in passing -- we should not be doing cancellations on people with indigestion or possible GERD who call 911. Even if previously diagnosed. I cannot count how many times I have seen someone who was previously diagnosed by a physician having a major cardiac event who dismissed their initial symptoms as gastrointestinal.

Attributing epigastric pain to one of these pathologies and failing to transport, even in the present of a "clean" 12-lead (sensitivity ~ 40%) is a really good way to dramatically decrease your future earning potential.

 

[Veneficus]

If you think you are doing something wrong...

Trying to protect yourself by adding in a caviat like: "I am not a doctor but..." or "I can't tell you what to do but what I would do is..."

probably doesn't do anything except make you feel like you protected yourself.

Documenting what advice you gave if other than "Let's get you to the hospital to be checked out by a doctor" is probably not the best way to give credibility to circumventing your scope of practice either.

In my past I have worked in a facility where dispensing OTC meds was part of the EMT-B scope of practice.

Our training was reading the lables on our down time. (or sometimes just before we gave it to somebody)

The consent form had a line about being temp. relief of symptoms and not a substitute for consultation with a doctor. (which we could even set you up with an appointment with if you requested)

I think a good perspective to consider is:

"What you would do" is based in large part to your knowledge of what could be the potential causes and when to seek help in the event your problem was not relieved.

For example, if you had menstrual cramps in the past, and thought you were having them again, you might consider it reasonable to dispense yourself something obtainable OTC.

If it were new or unusual symptoms, you might want to get something and seek out a doctor asap.

If you were chomping down the maximum listed dose of an OTC for more than a few days, you might consider going to the doctor.

If you munched down double or triple the dose and it didn't work at all or only minimally, you might go immediately to a doctor.

As a healthcare authority, you are generally responsible for dx and treatment of underlying pathology. Which may include things beyond the ability to dx on an ambulance or even what you know about. That is what doctors are for.

Keep in mind, most of the time you will probably be ok in your assessment and treatment suggestions. But if you are ever wrong, the blame will be focused on you.

The level of risk you wish to accept is entirely your decision.

As for what it will take to get medics to the level they can do this, it will take education at about the same level as a PA or NP in primary care prior to being able to make reasonable decisions with an acceptable level of risk.

There are just too many examples of grevious errors that have made the news when medics thought they knew what was wrong. Like TBI mistaken for intoxication or MI mistaken for GERD.

I wouldn't want to be the medic/basic named in the paper or a lawsuit for general malaise that turned out to be leukemia or a fever and flu like symptoms that turned into or out to be meningitis in a day or two.

Always recall the first rule of medicine. Punt on first down.

 

[MS Medic]

Well said.

 

[mycrofft]

Invert name badge. Read title

If it says EMT, then be an EMT. It's hard to care and be unable to render, but it's worse to go try to help people and maybe go around being right 50% of the time.

The horse goes before the cart. If one wants to prescribe ("recommend") even OTC one needs to get the right letters after one's name then get hired as whatever those degrees/certificates say.

We were granted entry into medical practice at a very basic technical level by the HIGHWAY administratin (not NIH) to follow protocols through prudent use of training andd without the depth and breadth of education needed to MOSTLY be right with surgical and medical dx and tx.

Even Good Sam won't protect one from prescribing as a layman; someone educated and hired with training not to prescribe is legally and civilly naked for a reason, and also not educationally qualified. (What if the patient's rash that OTC cortisone relieves is a fungus, or early lupus, or early skin cancer, or the herald spots of chickenpox?).

The alternative is to decide: get rid of basic EMT's and replace the with a more-educated class of practitioner (e.g., make PA the basic level of practitioner), or just delete prehospital EMS and go back to "get yourself in to a hospital" because EMTs become too undepndable.

 

[Veneficus]

Food for thought.

There is a saying in surgery that attempting to alieviate a surgical disease with medicine just delays a patient from getting the treatment they need.

Wouldn't trying to alieviate a medical or surgical illness with that available OTC or on an ambulance just delay a patient from getting the treatment they need?

another anecdote.

One family came to the station that had an injured child. (who had a laceration that obviously would benefit from stiches)

The parents stated they could not afford to go to the hospital, they were not going to the hospital under any circumstance, and would appreciate any help I could render.

The end result was me dressing the wound, giving them some materials to redress the wound, and instructing them on how to keep it clean and near begging them to go to the hospital.

Long and short, they thanked me, signed the refusal, and drove away. (Not to the hospital)

I wrote it up as treatment and refusal of transport. My employer was pissed and I was reminded that we get paid because we bill for transport, not what treatment we provide.

But, nothing I had done exceeded my scope. (basically evaluating, cleaning, and dressing a wound)

I did not inhibit these people from getting higher care. I did not recommend against or alternatives to higher care.

When you start deciding what is BS and what is "worthy" of an ambulance, which results in whether a patient perceives no need or limits access, I think you have crossed a line.

You may see a medical provider order the same treatment a million times. But not what goes into that decision and when to order another form of care. (that is where nursing creates trouble for itself)

As mycrofft said, there is a place to learn where to make decisions on who needs and what they need.

It is not paramedic or EMT school. Even surgery is only 1/5 skills.

 

[MS Medic]

Wanting to move forward as a profession is a noble goal. Personally think the reason people want to do things such as move our scope into community health is because we realize that those of us in EMS, both pre and hospital based, are playing with a broken toy. (Pardon the bad analogy). I believe that rather than trying to move into something new, we should be stepping back, looking at what we do have and improving that.

I apologize that the above statement isn't as profound or expansive as I would like it to be, but I'm apparently not the wordsmith some of you other guys are.

 

[Aidey]

I think Linuss was more thinking of patient who call and THEY refuse to go, not provider initiated refusals. When I end up giving advice it is almost always to people who weren't sure what to do and don't want to go to the hospital. I have had people who were seriously sick who refused to go. Sometimes they change their mind when we explain no one will force them to get treatment, but they can be made more comfortable, and others tell us to GTFO as they light another cigarette.

 

[FLdoc2011]

There is a saying in surgery that attempting to alieviate a surgical disease with medicine just delays a patient from getting the treatment they need.

Wouldn't trying to alieviate a medical or surgical illness with that available OTC or on an ambulance just delay a patient from getting the treatment they need?

another anecdote.

One family came to the station that had an injured child. (who had a laceration that obviously would benefit from stiches)

The parents stated they could not afford to go to the hospital, they were not going to the hospital under any circumstance, and would appreciate any help I could render.

The end result was me dressing the wound, giving them some materials to redress the wound, and instructing them on how to keep it clean and near begging them to go to the hospital.

Long and short, they thanked me, signed the refusal, and drove away. (Not to the hospital)

I wrote it up as treatment and refusal of transport. My employer was pissed and I was reminded that we get paid because we bill for transport, not what treatment we provide.

But, nothing I had done exceeded my scope. (basically evaluating, cleaning, and dressing a wound)

I did not inhibit these people from getting higher care. I did not recommend against or alternatives to higher care.

When you start deciding what is BS and what is "worthy" of an ambulance, which results in whether a patient perceives no need or limits access, I think you have crossed a line.

You may see a medical provider order the same treatment a million times. But not what goes into that decision and when to order another form of care. (that is where nursing creates trouble for itself)

As mycrofft said, there is a place to learn where to make decisions on who needs and what they need.

It is not paramedic or EMT school. Even surgery is only 1/5 skills.

+1 totally agree.

I even have to deal with this issue when things get out of my scope. A cancer pt may ask me how long they have to live or if they should continue chemo and while there's basic advice/instruction I can give based on my training there are definitely areas that are out of my expertise and I have to flat out tell them I can't answer that but can get in touch with someone who can.

Overall it's about knowing what you know and most importantly what you don't know and staying within your scope, whatever that may be.

I'm sure this is a hard/tricky issue on the EMS side, it still is for me as well.

 

[bstone]

"You should ask your doctor" is my reply. Can replace doctor with PA or NP.

 

[mycrofft]

Second that stone. The doctor-patient relationship, although not as personal nowadays, is still extant, both medically and legally.

 

[WuLabsWuTecH]

We can't advise them of any OTC drugs to take, but after they refuse, if they don't go to the ER, we can recommend that they go to an urgent care or doctors office for follow up. We can also give them advice on what to watch for and whether anything that might surface should be a cause for concern.

We're also allowed to hand out things like dressings, cold packs, and such to minor injuries. Often, the medics will advise mom, that their kid probably needs stitches after we clean out an injury, but that they are stable enough to go by POV if they so desire. We always offer to take them, but most people will decide not to have the hassle of an ambulance transport and will take them POV instead.

 

[the_negro_puppy]

We always tend to give advice. I always explain to the patient what their options are.

IF they have a minor ailment I say words to the effect of "the probably arent going to do much for you at the ED, but we can transport you if you wish" followed by- my advice is xyz, see your doctor, etc

 

[Veneficus]

We always tend to give advice. I always explain to the patient what their options are.

IF they have a minor ailment I say words to the effect of "the probably arent going to do much for you at the ED, but we can transport you if you wish" followed by- my advice is xyz, see your doctor, etc

You also have more education than 750 hours of vocational school.