Transporting a patient against their will to Trauma Center

LACoGurneyjockey

LACoGurneyjockey

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Would you transport a trauma patient to the Trauma Center, even if the patient is adamantly refusing transport to said facility and requests a less capable facility? For this case, the patient is CAOx4, victim of a MVA, C/O head and back pain with no other signs of trauma, no immediate life threats.
In accordance with my county protocol this patient needs to be transported to the Level 2 Trauma Center due to mechanism (MVA >45mph), however the patient refuses to be transported to this facility and instead requests a non-trauma center.
Now, my protocol states destination shall be determined by Case Specific Hospital criteria, patient choice, and disaster/ED closure. It also states patient choice shall not prevail over Case Specific Hospital criteria. I interpret that to mean if a patient requires Trauma/STEMI/Stroke specific hospital but refuses transport to that hospital and instead requests a less capable facility, I am to disregard that patient's choice and transport them against their will to the specialty center.
That sounds like kidnapping to me...
So I can break County Protocol, or I can break Federal Law, but I cannot abide by both. Obviously, Federal Law should trump County Protocol, but does anyone see any reason or logic in this protocol?
How would everyone have handled this situation? Is there anything I'm missing here?
Link to Kern County EMS Protocols attached at the bottom, and specific protocols quoted below.

KERN COUNTY EMERGENCY MEDICAL SERVICES DEPARTMENT
Ambulance Destination Decision Policies and Procedures
Policy #: 4200.6500 - .6599
Effective Date: 07/01/91 Latest Revision: 06/18/2013

The ambulance attendant is authorized to make the final decision regarding the
destination in accordance with these policies. The destination decision shall be
based upon a) current Hospital Emergency Department Status, b) any Case
Specific Hospital category applicable to the patient problem, c) patient or patient
physician choice, and d) the current Hospital Emergency Department Overload
Score as follows:

a. Current Hospital Emergency Department Status: if an emergency
department is on E.D. Disaster Closure Status, the patient shall not be
transported to that destination.

b. Case Specific Hospital: patient shall be transported to a Case Specific
Hospital if the ambulance attendant determines the patient will be best
served by capabilities of that facility, as specified in Section IV.D.

c. Patient or Patient’s Physician Preference: patient choice shall be factored
into the destination decision. But, patient choice shall not prevail over
E.D. Disaster Closure Status or Case Specific Hospital criteria.

http://www.co.kern.ca.us/ems/AmbHospEDPolicy33_06182013.pdf
 
I would call your MD, and let them be the deciding factor just to cover your butt considering there is a discrepancy within the county and federal laws.

ETA: I can sort of relate to this patient. Trauma center hospital in our area is always packed, the staff is snippy (or well, at least not as friendly as other hospitals), they're often inundated with patients, ER wait time is looooong, the have gone on diversion at least once recently, and more recently on one of my ride alongs I heard them trying to divert an ambulance with patient to another hospital without being officially on diversion. It was for all those reasons and more when my daughter was immobilized I told the EMT (my Captain) I wanted to go to a different hospital. She suggested the trauma hospital, I told her I understood why but I told her I felt most comfortable going to the other hospital and stated my reasons. I took full responsibility for wanting to not go to the trauma center. We ended up going to the other hospital. Granted, her accident was not MVA but she did have significant back pain and was not A&O at times.
 
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That protocol is clear and I'd want a lawyer's opinion about it. The patient ultimately can refuse service of any sort, but to withhold service because they won't go to your choice is indefensible unless the facility CANNOT accept them (overcrowded, on fire, etc).

E.G. (presuming pt is alert oriented and sane):

PT refuses to go to trauma center: protocol says take them anyway.

Pt refuses all care if your take them to trauma center and wants out of your ambulance: you are denying care if you deny to treat unless they go to the trauma center.

Pt refusal to go to trauma center, IAW protocols, is patient dictating care, not a good situation.


In a real situation, I'd try to find out why they don't want to go there to see if they are informed, seemingly competent, and maybe even have a good reason. Try to talk them into it, tell them you are required to at least take them there and they can call for another ambulance to take them to another facility (and let them argue with the ED).
 
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Seeing as our primary job is being a patient advocate I'd call a doctor at the trauma center and explain the situation. And ask for approval. Then I'd call a doc at the facility where they want to go and explain the situation.

I've had to do this more than once, including an 80 year old male that took about 20 minutes to extricate after he rolled a couple times into a pole at about 50. Never had any doc force me to transport to the TC. "I'd rather have them seen then not so I have no problem with you going there/coming here." The doc at the hospital the patient wants to go to will generally add "just explain to them that we aren't equipped to handle everything so if we find something we can't handle they're going to have to be transferred to the Trauma Center."

I don't understand why people are so resistant to picking up the phone and calling a doctor to circumvent a protocol.
 
What does EMTALA have to say on this?
doctor-with-crystal-ball-thumb9142479.jpg
 
EMTALA only applies to patients on hospital property or patients already under the hospital's care.

EMTALA basically says hospitals have to provide emergency care to anyone requesting it regardless of their ability to pay.

So with that the patient's choice hospital technically shouldn't be allowed to divert you but they are well within their right to transfer a patient out that requires services they aren't capable of providing. It could be argued EMTALA would require that patient to be transferred if they were beyond the hospital's capabilities.
 
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Ok.
 
vc85 said:
I think your state needs to fix those protocols.
Click to expand...

I agree.

Mycroft, on scene patient was refusing transport as long as we said "we have to take you to the trauma center". The only way to get the patient to accept transport to any higher level of care was to allow transport to hospital of choice.
Why is the patient dictating their care a bad idea?

The MD at the trauma center cleared transport to patient's choice, but the patient's choice hospital tried to refuse and divert to Trauma Center.
Come to find patient was convinced by ER Doc to be stat transferred to Trauma Center.
 
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When I went to Kern County EMS Update this year, they made a big deal that we are a "patient choice driven system." That being said, there are trauma AMA forms for Kern County for people specifically refusing transport to the trauma center as well as the ability to make base contact and have the trauma center clear a patient for transport elsewhere.

The mechanism you talk about is a "Step 3" trauma. Which is actually a trauma consult/consider trauma activation. It does not mean they will go there 100% of the time. (See trauma center policies and procedures) Mechanism of injury is not an automatic trauma center activation, only certain physiological presentations, and apparent injuries. With trauma center consult I have transported numerous Stem 3 patient's to non trauma facilities with no problems. When you think about it, especially in East Kern, you can't be transporting every MVA to the trauma center a couple of hours away or fly them out based on mechanism alone. Yes there are some small facilities in the county that like to stat transfer all trauma but those usually get downgraded within 10 min of arriving at KMC. Therefore, that is why the trauma consult exists. From what you described, that is the way things usually work out there.
 
CentralCalEMT said:
When I went to Kern County EMS Update this year, they made a big deal that we are a "patient choice driven system." That being said, there are trauma AMA forms for Kern County for people specifically refusing transport to the trauma center as well as the ability to make base contact and have the trauma center clear a patient for transport elsewhere.

The mechanism you talk about is a "Step 3" trauma. Which is actually a trauma consult/consider trauma activation. It does not mean they will go there 100% of the time. (See trauma center policies and procedures) Mechanism of injury is not an automatic trauma center activation, only certain physiological presentations, and apparent injuries. With trauma center consult I have transported numerous Stem 3 patient's to non trauma facilities with no problems. When you think about it, especially in East Kern, you can't be transporting every MVA to the trauma center a couple of hours away or fly them out based on mechanism alone. Yes there are some small facilities in the county that like to stat transfer all trauma but those usually get downgraded within 10 min of arriving at KMC. Therefore, that is why the trauma consult exists. From what you described, that is the way things usually work out there.
Click to expand...

I agree with everything you said, and I've heard the same thing about patient choice. KMC (oops, I mean vague Trauma Center) did clear the patient to go to the patient's choice facility. The issue was more on arrival at that hospital the ER did not want to accept the patient. Enroute they tried to divert back to KMC and on arrival they harassed the crew and eventually stat transferred to KMC.

I'm just trying to figure out if there's any point where the county actually wants us to disregard patient choice, and transport to the specialty center regardless.
 
call a supervisor or medical control to deviate from protocol.

Try to convince them to go to the trauma center. but when all else fails, document appropriately, including refusal to transport to trauma center, and take them where they want to go.

Patients have the right to make stupid decisions regarding their health care.

oh, and once they are on the hospital property (ie, the ambulance bay), the hospital cannot refuse the patient without being charged with an EMTALA violation.
 
If your patient is a&ox4 and makes his/her own medical decisions you can never ignore their request. If your protocol says one things and your patient say another have them sign AMA after explaining the risk vs benefits and then call the patients choice of hospitals to give report so they are not blindsided upon your arrival with a patient they do not typically receive
 
I had a similar pt a few years ago. pt was in a roll over. Our old protocols called for him to be boarded and transported to a trauma center (1.5 hours away). the pt didn't have a scratch. normal vitals and no pain other than his shoulder being a bit sore (seatbelt). he didn't want to go to the hospital but he agreed to go with us because his wife was freaking out and he wanted to put her mind at ease. Our dispatch lost their mind when we went enroute to our local er (10 min away) they told me the pt didn't have the right to refuse the destination. I was told that the pt could refuse all treatment and transport or accept all. I was almost suspended until the union stepped in and our cqi department backed me. I had the pt fill out refusal forms for the trauma center destination and SMR.
 
I had a somewhat similar situation once:

The city we were in had two hospitals, about 10 minutes apart. One was a level two trauma center with all the bells and whistles, the other was a community hospital that could just barely handle ortho, but was generally regarded as being nicer to it's patients.

Had a patient with an active MI who adamantly refused to go to the big hospital, and the state's laws did permit pt choice to trump pt need. So we called the small hospital, let them know what we were bringing them and why, after they spent 5 minutes complaining that we should go to the big hospital they resigned themselves.

Upon our arrival, we were met with effectively the hospitals rapid response team. They took the pt into a room, ran a 12 lead and pulled some blood, a few other things, the doc said "Yup, it's an MI, we're going to transfer you to Big Hospital", we loaded her back into our truck and went. Less than 10 minutes on scene, and the pt never got off our cot.
 
While we like to think that we generally know where the best transport destination is for a patient, we are not doctors. Sometimes people are in dire straights and will still refuse to go to what WE think is the appropriate place but will want to go thee preferred ED.

We can try until our faces are blue but some people just regard us Ambulance Drivers and not educated clinicians (which is something that we continue to allow in our chosen careers). But these same people will immediately agree to a transfer as soon as your local ED attending walks in and says what the heck are you doing here.

For your particular mva pt with head/neck pain who wanted to go somewhere else, explain to him that you have your instructions, however he still has a right to go where he wants against your advice, but to do so he will need to sign your refusal form and hen document that refusal signed upon explanation of your protocol and his possible need for a TC. Document document document.

Some rules are meant to be broken, some bent. Never ever ever ver transport somewhere against their will. Unless you can get them committed.
 
Milla3P said:
While we like to think that we generally know where the best transport destination is for a patient, we are not doctors. Sometimes people are in dire straights and will still refuse to go to what WE think is the appropriate place but will want to go thee preferred ED.

We can try until our faces are blue but some people just regard us Ambulance Drivers and not educated clinicians (which is something that we continue to allow in our chosen careers). But these same people will immediately agree to a transfer as soon as your local ED attending walks in and says what the heck are you doing here.

For your particular mva pt with head/neck pain who wanted to go somewhere else, explain to him that you have your instructions, however he still has a right to go where he wants against your advice, but to do so he will need to sign your refusal form and hen document that refusal signed upon explanation of your protocol and his possible need for a TC. Document document document.

Some rules are meant to be broken, some bent. Never ever ever ver transport somewhere against their will. Unless you can get them committed.
Click to expand...


Preach brotha, preach!

The last part is a valid point. The only thing I'd say is if that's your plan then have a legal hold placed prior to transporting them. What happens if you take them against your will and the clinician you're counting on to legal them disagrees with you and doesn't think they need to be held for 72 hours?

I've been asked multiple times why paramedics cannot place people on legal holds. The only answer I've found is a conflict of interest due to our agencies billon for transport. Argument being "they placed a legal hold on the patient just so they could force transport and bill for it."

Our cops are pretty good about if we call them to place a legal hold they generally don't ask questions even if the patient denies denies denies once PD shows up.
 
LACoGurneyjockey said:
Would you transport a trauma patient to the Trauma Center, even if the patient is adamantly refusing transport to said facility and requests a less capable facility? For this case, the patient is CAOx4, victim of a MVA, C/O head and back pain with no other signs of trauma, no immediate life threats.
In accordance with my county protocol this patient needs to be transported to the Level 2 Trauma Center due to mechanism (MVA >45mph), however the patient refuses to be transported to this facility and instead requests a non-trauma center.
Click to expand...

In all honestly, MOI protocols annoy the crap outta me. I know a lot of clinicians that believe that MOI is the end all to be all that's true.

Prime Example about a month ago a crew flew a patient to a trauma center (these guys get their jollies all up and fondle themselves thinking about whirly birds) based on the fact that he fell down a flight of stairs offered no complaints no LOC, all neuro was intact he had a couple of bumps and bruises. Theyre factor was "he fell down a flight of stairs" Mechanism of Injury suggests major trauma FLY HIM!! He was flown to the trauma center, and discharged within a few hours. Nothing wrong just a few bumps and bruises.

Last week I had a patient who flipped his truck on its side trying to avoid a deer, 50MPH he stated he was going. Seatbelted, Air Bag Deployment, and up and walking around upon arrival. Couple cuts and bruises, no real pain. other than being a little lumped up his physical exam proved unremarkable. I called the local Band Aid Community Hospital told them what I got they said yeah bring them in. I got so much hell for running a patient who was in said MOI with minor trauma BLS. The ED Doc said really there was nothing really wrong with him they just did some films and monitoring to be 100% sure sent him home by morning.

So I've been in your shoes where people or protocol states Patient must go to here. Where patient says oh no I don't want to go there I want to go here. Take it or leave it. I ask the patient why? they tell me, well its close to home or I don't like that other hospital or whatever they may tell you. Obviously the are CAOx3, have a self patent airway and are capable of making their own decisions do a complete physical assessment, with noted findings of DCAP-BTLS and call the doc. Say look his vitals are this, his physical exam is This. and he wants to come to you. If I don't take him to you, its he leaves me AMA. Your call?

Doc either says well bring him here will assess and decide or Let him AMA either way your have followed another protocol that relieves you of liabitlity for the patient
 
Mechanism of Injury (MOI) actually is an important part of a trauma assessment... but probably NOT in the way you might think. First off, all injuries have a mechanism. They don't happen spontaneously. Injuries are a result of forces being applied to the body in such a way that the body can not absorb the stress without damage. Forces applied to the body do NOT affect all parts of the body equally, in other words, if I apply a twisting force to your leg, your arm isn't going to also be twisted.

Now that we've covered that, here's what I'm going with this. When you approach a scene that could result in an injury, you look at where any forces could have been applied to the body, where those forces would impact the body, in what direction the forces were applied to the body, and so on. By looking at the MOI, you should have a really good idea where the patient is going to possibly manifest an injury. MOI tells me where to look. It does NOT tell me if actual injury occurred.

Someone that fell down the stairs is going to have a different MOI than someone that was shot, stabbed, electrocuted, or in a wreck. So, look at the MOI and if you know how to read it, you can figure out where to look for injury. If you don't find injury there, but you find an injury somewhere else that's not suggested by your reading of MOI, then either you misread the MOI or something else happened that you're not being told. When it involves kids...
 
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