Transporting a patient against their will to Trauma Center

Here, if a patient requires transport to a trauma center, they go to the trauma center. If they refuse, it is just like refusing any other transport. That is the only place they can go, so they have the option to go or to not go. You could be the crew that takes a patient to a hospital that can not handle them, but its pointless. Transfer would be required.

Same situation to as the squads that only transport to the closest APPROPRIATE hospital. If a patient refuses transport to that facility then they the liability is not ours. Our only required transport is closest facility.

For two of the organizations that I work for, there is only one hospital in a reasonable distance for transport. The other, we give choice as long as it is an appropriate facility. I agree that the choice should exist but what do your local laws require?
 
My local laws don't say much, but my Federal Law says if I take someone somewhere against their will its kidnapping. Why would you prefer a refusal on the side of the road than take a patient to a hospital, even if it's not the most capable. As someone said earlier, any hospital is better than no hospital.
 
As mycrofft noted, the key dilemma is that while a patient can't force you to do anything, you can't force them to do anything either -- they CAN refuse to go anywhere but their preferred destination, and that leaves you with the choice between a provider-initiated refusal (very bad juju) or taking them to their preferred destination.

They can say "my hospital or no hospital," in other words, and "no hospital" is rarely a real possibility.
 
I would not prefer a refusal over a transport, but that does not mean I would prefer to transfer where ever they want. Where is the line that we draw on what is acceptable and what isnt? Is taking a patient to a hosptial that is not a designated trauma center better than nothing? Not really. They still need a trauma center. Same applies to stemi center, stroke centers and even crisis. Its not a provider pushing refusal, its the patient, who is refusing.
 
ZombieEMT said:
Its not a provider pushing refusal, its the patient, who is refusing.
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Sure. Nevertheless. If things go badly, a lawyer's going to be asking why you wouldn't bring this patient to the hospital and they died. "To make a point" probably won't fly.
 
Can I ask where I said I was doing it to prove a point? It's not about proving a point, it's about the obligation we have two more than just one patient. We have a responsibility to the service area that we cover. This extends past one patient. We are not a taxi service, besides what people intend to use us for. It's about conserving resources. It's about what's doing best not only for that single patient but other patients that also require our assistance. I am all for allowing a patient to choose a different hospital but it does have to be in a reasonable distance and an appropriate facility. My question is, where do we draw the line? If I came to California from the East Coast and requested you transport me to Cooper in South Jersey and adamantly refused anywhere else, would you transport to Cooper? Again, what is the limit?

If you want to ring the legal aspect into it, then we are not liable. New Jersey requires that we only have to transport to the closest appropriate facility. That doesn't mean we are not allowed to transport to somewheres else, but we are not doing anything legally wrong if we only transported to the closest appropriate. I think the keyword remains appropriate.
 
On the street your job is not to worry about coverage, that's a manager's job. Your job is to be a patient advocate.

Of course no one is going to drive across the country, to use that as an example is pretty ridiculous.

We will take patients to any hospital in our county and I've been approved to go one county south from the southern end of our coverage area because that's where the patient wanted to go.
 
I agree all around. But again, there is always the possibility of someone you think is very sick saying: "No -- if you don't take me to Hospital X, I'm refusing transport." And then you either have to relent and take them to X, or let them refuse, and then you're the guy who let a very sick patient refuse, probably the most high-liability situation we encounter (other than dropping people on their heads). It's one thing if you did everything you possibly could to convince them to come to the hospital and they just wouldn't listen -- but in this case, there IS a way to get them to the hospital, you just don't want to do it.

I'm not saying you have to do everything under the sun just because a patient blackmails you by threatening refusal. But there's no clear threshold where it's obviously unreasonable (in your example of the long-distance transport, how far would you go? if your policy says 30 minutes and they want to go 31, will you really put your foot down and leave them at home?), and if a bad outcome actually results a poo-storm is probably totally inevitable, even if you're eventually vindicated.
 
Agreed. It's not the field providers job to worry about coverage, who's staffing what and how many units are in service. It's the field providers job to take the patient where they're best served. In a fully conscious and oriented patient, that's the hospital they want to go to.
 
If a patient is competent and informed, they can refuse.
You can argue with them.
You can prove they are not competent and have LE back you up as a 5150 (threat to self or others).
 
mycrofft said:
If a patient is competent and informed, they can refuse.

You can argue with them.

You can prove they are not competent and have LE back you up as a 5150 (threat to self or others).
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Even on legal holds I let the patient pick the hospital they go to. We're stripping them of most of their rights already why not give them at least something back?

Can you imagine the ambulance personnel and law enforcement coming into your home/life and forcing you to go to the hospital against your will? Then not even being allowed to pick where you go?

They'd have to dart me.
 
mycrofft said:
If a patient is competent and informed, they can refuse.
You can argue with them.
You can prove they are not competent and have LE back you up as a 5150 (threat to self or others).
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As much as it may be tempting though, woe unto the provider who uses this to corral an uncooperative but fully competent person. People have the right to make even obviously bad decisions if they have a functioning noodle and understand the consequences.

Again, just remember that no matter what he's signing or what you document, when the lawyer asks later, the patient's not going to say "I didn't want to go to the hospital"; he's going to say, "I wanted to go to Hospital X and that medic wouldn't take me. He said he'd only take me to Hospital Y or else nowhere." And that's gonna be a fun couple of months.
 
Why isn't it a field provider's responsibility to worry about coverage? Again, we have an obligation to the community and our service. I did not get into this business to help one patient. Look at the big picture besides just one. I work as a street provider, not in management, that does not mean I do not care about the rest of the community and patient, taxpayers and customer. I worry about all my patients receiving fast and quality care. If that means I am not going to take a pateint further or to an innappropriate hospital when they dont need it, I am fine with that. It is more than just one patient. What is your reasoning, that you dont have to tell the other patient's tough luck (because you never reach them) but the one in front of you might be upset if you tell them tough luck?

I have never had a patient that was critically ill and wanting transport to a different hospital outright refuse. Most people smarten up when the situation is explained. I explain it as a life and death. IE, a patient that needs a cath lab for a stemi, I explain to them the consequences that can be created if they refuse to go. They might not be happy with where they are going, but they will get there and have a better chance at survival. If they still want to refuse and are CAOx4, thats their right.

Yes California to NJ is completely unreasonable, but where is the line drawn? Yes that is extreme, others might argue the hospital that is 45 minutes away is extreme compared to the closer appropriate faciltiy that is only 10 minutes away. Where is the line?
 
I drew the line did I not?

It really isn't your job, it is the system status manager's job to distribute units in a SSM system and the dispatcher's job to have outlying stations cover central stations when needed. If there are inadequate resources to cover the county your agency needs to staff more units, it's as simple as that.

We don't play the "what if another call pops" card. The patient that called first and you are with is your patient. They are your customer, the majority of this job is customer service. I'll tell you this right now, if you took me to a hospital that I told you not to it wouldn't end well for you or your agency.

I've had critically ill patients refuse transport to the nearest facility because they didn't like it. Now in my situation it's usually only a 5-10 minute difference. Like I said though I've taken people to the Medical Center in the northern end of the county just south of us before after clearing it with a supervisor.

I agree, we have a duty to the community and that is to provide care and advocate for them when they're our patient. I'm not asking you to drive two states or when two counties over, I never said that.
 
ZombieEMT said:
I have never had a patient that was critically ill and wanting transport to a different hospital outright refuse.
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No, it usually doesn't get to that point. That's why this isn't as big of a dilemma as it could be. Usually you can persuade, cajole, convince, or even BS someone into a somewhat-reasonable decision. But whenever we do, we're bluffing a little bit, because we know that in the end, they have the trump card. We won't literally leave them there to die.

At least, I wouldn't, and I presume you agree that transporting to the wrong destination is better care than transporting nowhere.
 
You certainly did draw a line but is that your company standard, county standard, state standard or national standard? Also, while it might not be my personal job to worry about specific staffing needs or coverage, it is our job to be resourcesful and conserve a resource when available. I restate the fact, I did not get into this for one patient, its the overall picture. So who's to say that does not start with you.

In a perfect world, when staffing is short or trucks have extended transport, we would have someone to make sure trucks get staffed but its not a perfect world. The reality is that its not that simple and EMS as a whole is not that simple. A truck will not just staff itself when one crew just decides to go on a 45 minute trip vs a 15 minute trip. There is nothing wrong for advocating for your patient, but that doesn't mean that you pick them up and do what ever they want.

Is EMS customer service? To an extent it is. Reality of it is though, in a real consumer market, if you dont pay, no service. Not the same in EMS. Many times the insurance companies are our customers. Medicare/Medicaid and private insurance is our customers. Do we have to treat our patient with good customer service and overall like a decent person, but they will not refund the service and we certainly do not just give them what they want because they want it.
 
Brandon O said:
No, it usually doesn't get to that point. That's why this isn't as big of a dilemma as it could be. Usually you can persuade, cajole, convince, or even BS someone into a somewhat-reasonable decision. But whenever we do, we're bluffing a little bit, because we know that in the end, they have the trump card. We won't literally leave them there to die.

At least, I wouldn't, and I presume you agree that transporting to the wrong destination is better care than transporting nowhere.
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I actually disagree. Transporting a patient to a facility that can not manage the patient, is just as bad as not transporting. If the patient is having an acute STEMI and they need a cath lab, they need a cath lab. Not a ECG at your local ED with minimal capabilities. If a patient has life/death traumas, they need a trauma surgeon not an ER doc. A patient with a CVA needs a stroke center and TPA, not a IV and saline. There is a window of time and it is not large. Ultimately that patient will have to be transported to that appropriate facility. The only thing you are doing is delaying transport and passing the buck to someone else.

I think its a horrible idea to let them refuse but transporting them to a hospital that is not appropriate is just as bad if not worse. Thats why you convince them, show them that you are serious, go over consequences.
 
ZombieEMT said:
I actually disagree. Transporting a patient to a facility that can not manage the patient, is just as bad as not transporting. If the patient is having an acute STEMI and they need a cath lab, they need a cath lab. Not a ECG at your local ED with minimal capabilities. If a patient has life/death traumas, they need a trauma surgeon not an ER doc. A patient with a CVA needs a stroke center and TPA, not a IV and saline. There is a window of time and it is not large. Ultimately that patient will have to be transported to that appropriate facility. The only thing you are doing is delaying transport and passing the buck to someone else.

I think its a horrible idea to let them refuse but transporting them to a hospital that is not appropriate is just as bad if not worse. Thats why you convince them, show them that you are serious, go over consequences.
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If the patient makes their own informed decision about going to the "wrong" facility, then that's their choice and you need to document the hell out of it. To take them to a place that's isn't their choice, especially after you've informed them of what they truly and likely need, you're kidnapping them. You might beat the "rap" in the "interests of justice" but that doesn't mean that they won't call the cops on you. You very easily could end up taking a ride to jail in the back of the ever-so-comfortable police car.

If a patient is adamant about going to an inappropriate facility, explain to them what can happen, get the OLMC involved and have them speak to the patient on a recorded line, and if the patient persists, they're free to AMA, though I won't initiate a refusal of service on a patient that needs to be seen, but if, after all that, the patient still wants to go to an inappropriate facility, I'll take them there. Even a minimally capable facility has better resources than my ambulance does.
 
People are allowed to make bad decisions. That's the beauty about living in the United States my friend.

Akula put it out there, if you give them the information they need to make an informed decision, they understand that information and make a bad decision based on it who are we to play god and overrule them? That's kidnapping. Assault and battery could easily be argued as well. I'm gonna tell you this, you saying they were making a dumb decision and you knew what was best for them isn't going to protect you in a court of law or your income or your ability to provide for your family. At what point do you need to consider those aspects of it? What would your husband or wife say if you came home and had to tell them you didn't have a job anymore because you forced someone who didn't want to go to a certain facility to go to that facility and it blew up in your face?

We provide services to everybody because of EMTALA which says life saving/sustaining treatment will not be withheld despite someone's ability to pay for said services.

It's incredible to me how little people know about the legal side of EMS.

You can't save the world so stop trying now before you burn yourself out.
 
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Frankly I'm surprised this discussion is even occurring. A competent patient ALWAYS has the right to refuse treatment or transport, and any part of treatment or transport, period. End of discussion. Nothing more to see here.

As Brandon points out, it rarely actually gets to that point. Some persuasion almost always works. Then there's always the option of the cops saying "Look, if you don't go with them I'm going to arrest you for <they can make up some complete BS reason> and you are going to jail. Would you rather go to jail than the hospital?" But I really prefer not to go there personally, and of course cops aren't always around.

ZombieEMT said:
Transporting a patient to a facility that can not manage the patient, is just as bad as not transporting.

I think its a horrible idea to let them refuse but transporting them to a hospital that is not appropriate is just as bad if not worse.
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I'm sorry, but these two statements are ridiculous. You are thinking far too black-and-white and ignoring the fact that life and medicine are actually mostly grey.

I have a hard time believing that you honestly think that it may actually be worse for a sick patient to go to a local ED than to be left in a ditch on the side of the road....

You do realize that even a small community ED can do airway management, IVF and blood product resuscitation, administer fibrinolytics and hemostatic agents, and that they may even have surgeons on call who can come in and do many of the same things that can be done at a trauma center? Did you ever consider that the ED staff may have better luck persuading the patient that they need to go somewhere else?

When we talk about patient advocacy, that means advocating for the PATIENT'S interests, not your own. A big part of advocacy is taking what little you can get and realizing it is better than nothing, in terms of what your patient will agree to.

Yes, the local hospital probably does not have interventional radiology or a trauma team, but that doesn't mean they are incapable of doing things that might be beneficial.
 
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