What should have been done?

[ClarkEMS]

I had a patient today who called campus EMS because of right side abdominal pain. On arrival the patient was conscious and alert and it seemed like the only problem was the pain which was seemingly very extreme. We took vitals and tried to talk the patient into going on an ambulance (protocol for us), but the patient refused and we called a taxi. The patient walked down the stairs with us just fine but once we reached the bottom floor the patient crashed. The patient was sweating bullets and looked so pale, a complete difference from when we first arrived. Needless to say I got a BLS truck on scene and patient was transported, but I can't help but think that we could have handled this better...any suggestions?

 

[Epi-do]

If the patient was A&Ox3 and you explained the possible complications associated with their complaint, there really isn't anything you can do. It sounds to me like you did all you could, including getting the ambulance there once the patient's condition changed.

 

[ClarkEMS]

I agree, especially when me and my two partners were going over what happened we decided that we did everything we could at the time. The worry was more that we might have aggravated whatever it was that was bothering the patient in moving them down stairs. Though, once again, I don't think there was any other way, but the patient just absolutely deteriorated when we reached the bottom floor. Vitals were strong, but the patient looked sweaty and pale and was most definitely in a lot of pain...

 

[medic417]

As long as you actually tried to convince person to go and did not hint that they were fine and could go on their own and they were were competent adult nothing else you can do.

 

[VentMedic]

I had a patient today who called campus EMS because of right side abdominal pain.

The patient called EMS? Not a bystander or Significant Other?

What was the patient's expectation of EMS? Did he just ask for an opinion or reassurance that it was nothing?

What could you have said that may have led the patient to believe he could go by taxi if he was the one who called EMS?

it seemed like the only problem was the pain

Did you use statements like "your vital signs are fine"? or "I don't think it is anything too serious" or "this is your only problem?".

Was your tone casual to almost bored or serious? Body language?

Even if you said "but I think you should still get checked out" after those statements, they may have stopped listening after they heard what they wanted to hear...reassurance that it was nothing.

Some patients will hang on to your every word even if you don't believe what you said is a big deal. This is especially true of people having a cardiac event.

If the patient was A&Ox3 and you explained the possible complications associated with their complaint

A&O x3 may mean very little in court unless you have excellent documentation or can get a signature on something that they understood what you said. Getting a signature from a witness to the conversation may also be helpful especially if it is a friend or family member who says they will see the patient follows through with your advice.

This is why some hospital procedure and surgical consent forms have a space for the patient to write what they believe the procedure to be in their own words. Even if they just write "cut me open and may die", at least they got the highlights of conversation. You might also look at the paperwork an ED discharges a patient with. It leaves little to chance and puts the responsibility to the patient. Although, that too can be argued it is of little use in the court room for some situations.

 

[medicdan]

Heh. Clark, we have talked about this before.... lol
On his particular campus, patients can receive a free taxi voucher if they call EMS for a non-emergency complaint, are assessed and sign a refusal.
I agree, you couldnt have done anything different re: advising the patient of risks of refusal. You did right in calling for BLS as soon as the patient deteriorated.
I am more interested in the underlying condition of the patient. What were the vitals? Can you recall the SAMPLE history? OPQRST? Did you palpate the abd? Do you have a way of finding out patient outcome? Were you the senior on the call?

This could be an interesting case review for your entire corps. Its a good reminder both that patients can turn at any time, and a good way to review the acceptance of refusals.

 

[VentMedic]

On his particular campus, patients can receive a free taxi voucher if they call EMS for a non-emergency complaint, are assessed and sign a refusal.

That can be another point that any legal person could bring up.

At anytime did you imply a FREE taxi vs an ambulance that will cost more than college student makes in a couple of months?

 

[ClarkEMS]

Yeah, which they did, the patient refused after I said it would be a good idea if they were to take an ambulance which was fine by me, though my partners were concerned, I knew that the patient was competent and I talked about the ambulance a few times and all those times they said no. After seeing deterioration I sat down with her and said that if she went in a taxi she might not be seen right away and that at least in an ambulance she could be watched over and would go straight in. That turned her, plus I think she was in excruciating pain. I was mainly on the radio with dispatch, I should have caught this, but I didn't until after it was already done that my partner did not check respiration nor palpate abd. The vitals were fine though, solid BP, Pulse was not bad. I checked respiration the second time around with vitals because my partner didn't seem interested in taking them and found that she had what looked to be slight shallow breathing and I asked her about it and she said it wasn't painful to breath, though she did mention that she did have a little trouble, but she was speaking clear sentences to me, she wasn't short of breath and her resp count was perfect. The patients pupils were fine until she got downstairs when they suddenly dilated. The SAMPLE checked out, nothing jumped out at me from what she said other than this was the first time it had happened, the lack of food eaten, and the amount of pain. In the end, I believe my only mistake was not watching my partner, who should have been looking at breathing. I was senior on the scene which is why I am running this 20 times over in my head of what I could have done wrong and how to do better next time. This was my first call back on campus and my first as a senior member so it was a little stressful to say the least.

 

[ClarkEMS]

That can be another point that any legal person could bring up.

At anytime did you imply a FREE taxi vs an ambulance that will cost more than college student makes in a couple of months?

Yes, I explained that the taxi was free, which I think at first sounded great to her, and the ambulance is covered through Clark insurance. when she turned bad though, I explained her options, the taxi she knew was free, but it didn't guarantee that she could get care immediately if needed. It was when she turned for the worst that I said an ambulance might be a good idea for her considering the amount of pain and the fact that she did not look like she was doing well at all. And I still kept the refusal form with the report to cover all my bases. Oh and her two friends as well as two other EMS members were there to witness the signing of the refusal so there was no problem on that front legally.

 

[Veneficus]

just some points to consider,

a female of childbearing age complaining of R abd pain, I don't think breathing rate was going to make much difference in your treatment.

Acute surgical conditions would be more along the lines of thinking. Nobody is asking you to diagnose the problem, but I always like to plan for the worst and go from there.

ruptured ectopic pregnancy
abrupto placenta
ruptured appendix
ruptured ovarian cyst
perforated bowel
or the college campus issue of acute liver failure.

would be my top list. Not exactly diagnosable in the field, but certainly life threatening and things I hope basics are at least aware of.

 

[VentMedic]

Yeah, which they did, the patient refused after I said it would be a good idea if they were to take an ambulance which was fine by me, though my partners were concerned,

Yes, I explained that the taxi was free, which I think at first sounded great to her, and the ambulance is covered through Clark insurance. when she turned bad though, I explained her options, the taxi she knew was free, but it didn't guarantee that she could get care immediately if needed. It was when she turned for the worst that I said an ambulance might be a good idea for her considering the amount of pain and the fact that she did not look like she was doing well at all. And I still kept the refusal form with the report to cover all my bases. Oh and her two friends as well as two other EMS members were there to witness the signing of the refusal so there was no problem on that front legally.

No, the way you have presented it here, you essentially talked her into the taxi. That is how it will be presented.

Oh and her two friends

Her other two friends may be very helpful in backing that up.


Your show of indifference by "which is fine by me" may also be used if it was picked up on by either the patient, bystanders or your co-workers.

Your job is not to be a financial consultant waving a free taxi voucher. You should have discussed only the medical situation and then presented the options. It is not easy to back paddle once you've sold the patient on an idea and the fact that they may actually have trusted you as a medical authority.

Review Veneficus' post. Review the many diseases that can happen to a young person. Bad things happen to the young also.

Review what your refusal form says. Does it say refusal of medical care? Against medical advice? This patient was not refusing medical care. Apparently she was just taking your advice and once the ambulance was presented by YOU as what she SHOULD do, there is not really a "refusal" here.

 

[ClarkEMS]

just some points to consider,

a female of childbearing age complaining of R abd pain, I don't think breathing rate was going to make much difference in your treatment.

Acute surgical conditions would be more along the lines of thinking. Nobody is asking you to diagnose the problem, but I always like to plan for the worst and go from there.

ruptured ectopic pregnancy
abrupto placenta
ruptured appendix
ruptured ovarian cyst
perforated bowel
or the college campus issue of acute liver failure.

would be my top list. Not exactly diagnosable in the field, but certainly life threatening and things I hope basics are at least aware of.

Well, there is the first problem, we aren't all EMTs on the squad. A bunch of us are being put through EMT training through the school which is what I am doing, otherwise everyone is a first responder. I immediately thought of pregnancy problems or appendix and a few other things which is why in the end when she turned bad I called BLS instead of sending her in the taxi.

 

[VentMedic]

Well, there is the first problem, we aren't all EMTs on the squad. A bunch of us are being put through EMT training through the school which is what I am doing, otherwise everyone is a first responder. I immediately thought of pregnancy problems or appendix and a few other things which is why in the end when she turned bad I called BLS instead of sending her in the taxi.

I would love to be an attorney for this patient. Keep your stories straight. You would be very easy to trip up in a legal depo.

I agree, especially when me and my two partners were going over what happened we decided that we did everything we could at the time. The worry was more that we might have aggravated whatever it was that was bothering the patient in moving them down stairs. Though, once again, I don't think there was any other way, but the patient just absolutely deteriorated when we reached the bottom floor. Vitals were strong, but the patient looked sweaty and pale and was most definitely in a lot of pain...

Yes, I explained that the taxi was free, which I think at first sounded great to her, and the ambulance is covered through Clark insurance. when she turned bad though, I explained her options, the taxi she knew was free, but it didn't guarantee that she could get care immediately if needed. It was when she turned for the worst that I said an ambulance might be a good idea for her considering the amount of pain and the fact that she did not look like she was doing well at all.

The vitals were fine though, solid BP, Pulse was not bad. I checked respiration the second time around with vitals because my partner didn't seem interested in taking them and found that she had what looked to be slight shallow breathing and I asked her about it and she said it wasn't painful to breath, though she did mention that she did have a little trouble, but she was speaking clear sentences to me, she wasn't short of breath and her resp count was perfect. The patients pupils were fine until she got downstairs when they suddenly dilated. The SAMPLE checked out, nothing jumped out at me from what she said other than this was the first time it had happened, the lack of food eaten, and the amount of pain. In the end, I believe my only mistake was not watching my partner, who should have been looking at breathing. I was senior on the scene which is why I am running this 20 times over in my head of what I could have done wrong and how to do better next time.

Since you are only a First Responder, let this be a good lesson to get medical help and stop putting all your bets on a piece of paper. You are NOT qualified to assess medical emergencies as to whether they need treatment immediately or not.

 

[Veneficus]

Well, there is the first problem, we aren't all EMTs on the squad. A bunch of us are being put through EMT training through the school which is what I am doing, otherwise everyone is a first responder. I immediately thought of pregnancy problems or appendix and a few other things which is why in the end when she turned bad I called BLS instead of sending her in the taxi.

Wasn't trying to lay into you or anything, but give you some things to think about. You must forgive me as I have not taught first responders since 2003 and basics since 2004. I have no idea what they are teaching in those classes now a days. But I do hope that it is the names of life threatening emergencies and when in doubt call 911.

Not singling you out, but I do worry your system puts you at undue risk. First responders getting signed refusals seems a bit shakey to me. How could you possibly defend you made clear the nature or seriousness of the patient condition? I only know about you what you have written here, but you seem like a decent person and i'd hate to see you wind up in hot water over short sightedness on the part of your system.

The refusal may not have been because you convinced her to, but in western society you must be aware that especially in front of peers, young adults may not be completely forthcoming with information that will be medically pertinant. I think it might be safer calling a squad as soon as you think it is an emergency.

just my opinion, but you know what opinions are like.

 

[triemal04]

So...you have essentially no medical knowledge, education, or training, and you are responding to people that otherwise would be getting a responce by qualified paramedics? This is why campus EMS is a worthless idea unless they are ONLY acting as first responders for a couple of minutes until an ambulance arrives.

The abd can be a complicated enough area for an experienced provider, let alone someone in your position. This is evidenced nicely by your thought that all you did wrong was not watch your partner. Nothing personal, but there you go.

Just out of curiosity, after the pt "deteriorated" why did you call for a BLS ambulance? What do you really think they would do for this girl that you couldn't? Hint- the answer is nothing.

 

[knxemt1983]

just a thought...

Not singling you out, but I do worry your system puts you at undue risk. First responders getting signed refusals seems a bit shakey to me.

off topic but here's something to suggest for future cases. At my first squad, I was only a FR, and they sent us out on stuff but there were two backups.
1. we had an Ambulance coming
2. if we canceled the ambulance and it wasn't a totally false call, we had to contact med control and get there permission for a refusal AMA, and 9 out of 10 times the doc would talk to the pt.

just a thought I had, don't know how feasible it is where you are though

 

[knxemt1983]

So...you have essentially no medical knowledge, education, or training, and you are responding to people that otherwise would be getting a responce by qualified paramedics? This is why campus EMS is a worthless idea unless they are ONLY acting as first responders for a couple of minutes until an ambulance arrives.

The abd can be a complicated enough area for an experienced provider, let alone someone in your position. This is evidenced nicely by your thought that all you did wrong was not watch your partner. Nothing personal, but there you go.

Just out of curiosity, after the pt "deteriorated" why did you call for a BLS ambulance? What do you really think they would do for this girl that you couldn't? Hint- the answer is nothing.

seriously? he's a first responder, probably new to the field and at least he came here to learn what went wrong, cut him some slack. I agree it was wrong, and mistakes were made but it's a learning process, I was there in his shoes once, as I;m sure you were too, unless your one of those medics who thinks they never made a mistake, boy I know I have made some, but I;ve learned from each and every one, and thankfully no pt was harmed seriously in the process.

to the original poster, what i would have done is this:
-called for a ambulance immediately
-not worried about money or insurance, that's not the issue at hand
-advised the pt of the complexity, and importance of the ABD organs
-advised them that time could/ is of the essence and advanced test are needed
REMEMBER
-if she was still refusing to go let me ambulance come on in, and evaluate her
-basically do everything you can to cover your rump, remember we can will and should be held accountable to our decisions
- always refer to higher medical training if you're unsure
-always watch your partner, especially in an unsafe situation (not that this was, just a soapbox of mine
-whether you asses or your partner asseses, make sure it is complete thorough and sytematic. I let my emt partner assess just about every pt, but I listen to everything she ask and says and point things out as she goes. thats something we've worked on over time, but remember, it's your license and your caboose on the line too, saying I wasn't watching my partner is not a valid reason in court.

just some info for ya.

 

[Veneficus]

off topic but here's something to suggest for future cases. At my first squad, I was only a FR, and they sent us out on stuff but there were two backups.
1. we had an Ambulance coming
2. if we canceled the ambulance and it wasn't a totally false call, we had to contact med control and get there permission for a refusal AMA, and 9 out of 10 times the doc would talk to the pt.

just a thought I had, don't know how feasible it is where you are though

The point you make here is that the patient usually would speak to the physician. That is very different from a first responder explaining to a patient conditions and consequences for not gong by ambulance. It could be argued that the FR didn't provide complete or proper information to make an informed decision to refuse. I do not hold the provider at fault, but the system that allows or encourages FRs to hand out taxi vouchers or accept refusals based on their advice to a patient puts the provider at significant legal risk.

I think FRs and campus EMS have valid roles to play, but the system must be set up properly to provide patient care as well as have legal backing for providers. As vent pointed out, if this girl files suit, these providers most likely would lose in a big way.

 

[Labareda]

Everyone makes mistakes. There is no perfect EMT, there is no perfect Paramedic as there is no perfect Nurse. For christ sake there is no perfect Medic either.
You should have called the Ambulance right away, even if the vital signs where fine you should have told her that she needed transportation and that you would have to call an ambulance. Even if it would cost to her, at leas you would have been with your conscience clean.
But what is done is done, what was her problem after all? Ever talked to her again?
Everyone makes mistakes learn from it, its the only thing that can be done now.

 

[boingo]

How does one summon campus EMS? Do students call the campus police, or a different number? If they feel they need an ambulance, shouldn't they cut out the middle man and just call 911? Just curious.