When Not To Transport

jefftherealmccoy

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I recently moved to Idaho where I have encountered a very different view of patient transport than I am used to. I was wondering what the view is elsewhere and if anyone shares the same view as either of the two states I've worked in.

So in my previous state (won't mention where) it is the general concensious that when a person calls 911 for an ambulance, they go to the hospital. Even if you get there and there is obviously no problem, they are a frequent flyer, or they don't want to go. I was told by an instructor, "It is your job to convince them to go if they call us. No matter what." This is the CYA attitude that is taken on by most people. I worked with at least 5 different departments around the state while I was in medic school and all of them take the same approach.

In my current department it seems that the Paramedics are a lot more comfortable in telling people there's nothing wrong with them and there's no reason for them to go. And in some cases straight up telling them that they are not going to take them, period. This is partially because we have a medical director who is very confident in our assesment skills and except in rare cases we can't deny a patient who says "I want you to take me to the hospital."

Is there a general attitude in your states or departments that follows one or the other? Or something different?
 

sir.shocksalot

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Here in CO the general trend I have seen is that if they wish to take an ambulance to the hospital then that's generally what happens. If someone really doesn't need an ambulance ride the phrase that I've seen and used is: "Either we can take you to the hospital ER or you or a family member can drive you there." I personally always inform the patient of the risks of not going into the ER when they want to drive themselves in that way if they don't drive themselves into the ER I have myself mostly covered with the refusal. A great example is hypoglycemic patients, they almost never go to the ER with us. We give them some sugar, make sure they eat, have them sign a refusal and go on our merry way.

Some services in CO have alternative transport options like sending drunk people in a detox van or cop car to detox. I would say CO is pretty liberal with letting people stay at home or drive themselves in. That all said if they insist they need an ambulance ride then they get one. I rarely see anyone saying that they will not take someone that requests transport.

I think most states except parts of CA are this way (yes I know there are some great services there, we all know I'm talking about the big city FDs). Hopefully you will get adjusted to your new employer's way of doing things soon. As a bit of advice: when in doubt, always go on the cautious side of the fence and recommend transport. I know when I was newer (I'm still kinda new though) I probably went too far recommending to patients that they drive themselves in or that they don't need to go, thinking I was cool by not transporting "BS" calls. I've grown as a provider and realized how lucky I was that none of that has bit me in the butt. As it turns out what you don't know can hurt your patients. Sometimes a lift assist isn't just "too old to get up", a punch to the head isn't just a bruise, and a drunk person isn't just drunk.
 

Melclin

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I'm from Australia so we have a pretty different approach in some of ways. Just for a little bit of variety, I'll give you the 50 cent tour of how we do things.

We don't tend to consider that a 000 (911) call means a patients wants to go hospital. A good little bit of PhD research done here a while back showed that patients didn't necessarily want to be transported and they often didn't consider their issue to be a 'medical emergency'. They call because they lose the ability to cope with a situation that is healthcare related. Either the problem is legitimately overwhelming or the pt has a reduced coping capacity or somewhere in between. Either way they're usually just looking for someone who knows what they're doing to turn up, tell what they're problem probably is and provide them with some advice on what to do about it.

I usually work in one of three ways:

1. Pts that need to go. I basically won't take no for an answer. Acute coronary syndromes...etc.

2. Pts who don't need to go in an ambulance or don't need to go at all. "I cut my finger but I didn't wanna wait in the ED waiting room so I thought I'd get in quicker if I called an Ambulance". "It doesn't work like that, you don't get in any quicker and please don't call again in the future for that reason alone. That finger does, however, need to be cleaned and closed properly so your brother here is going to drive you down to the ED".

3. This is the tricky section and a lot of patients fit into this category. This pt fits in between 1 and 2. So I sit down with the patient and we have a good long chat. I explain the results of my assessment, my limitations, the possible causes of their problems, what the hospital might do about it and what the outcomes might be. Everyone is different and happy to accept different levels of risk, inconvenience, pain etc, so the same course of action may not be appropriate to everyone even if they have the same problem. After the patient has been informed of the issue at hand to the best of my ability, we come up with a care plan together. For some, its as simple as driving them to hospital. For others it might mean, sit on it for a little while, see how it goes and drive to the hospital if it doesn't improve within x hours. Maybe its a phone call to the patient's daughter to explain that the pt has an empty fridge, an empty stomach and needs more care at home. Maybe its ringing their GP to organise a review of their medications because they've been feeling very nauseated and strange in the head every since they started on that Tramadol. Any which way you look at it, myself, my partner, the pt and any family present all settle on a plan that everyone is comfortable with.

In this category, it is important that patients/carers understand that medical problems are dynamic. Just because at the time of assessment, problem x seemed the most likely, things may change 6 hours later, and those eventualities need to be explained as well as the fact that just because it did turn out to be problem Y in the end, that doesn't mean anyone, hospital included, were going to figure that out 6 hours ago.

I left a teenager at home with 20 mins of transient spasmodic minor abdominal pain after taking some paracetamol/codeine for a headache. After a good chat, he and his parents were happy to stay at home and I advised them that it was probably a fairly common adverse reaction, but that other possibilities like appendicitis were things that could not be ruled out based on the story. The plan that was best for them was, simply put, to see how it went over the course of the night and self present if one of several changes in his health became apparent. I made a list of them and everyone agreed on the plan. The next day, I saw him in the ED. His pain had evolved and was now obviously appendicitis. This, to my mind, was not a mistake. Quite the opposite. The plan had worked perfectly and he and his parents we more than happy with how everything turned out. This approach keeps 20 tummy aches out of the ED, sees ambulance resources freed up quickly rather than spending hours transporting and waiting at hospital with patients that don't need to be there, and means that the one tummy ache that was more serious, still got exactly the care it needed in a timely and appropriate fashion.

EDIT: RE refusing people transport who really want to go. It just doesn't come up that much. As far as I'm concerned, the cut on the finger that demands ambulance transport to the hospital will, in the end, get it. I don't feel like subjecting myself to a potential complaint and it doesn't come up often enough for it to be a problem. When this does happen occasionally, I usually drop them at the front door and have them walk into triage themselves....just to make the point that you don't benefit in anyway from calling us if you don't actually need us.
 
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Handsome Robb

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We cannot refuse to transport someone. If they want to go they get a ride. I have no issue giving someone a ride...no skin off my back and a transport chart is easier to write than an AMA. There are extreme circumstances (ie you've seen that patient multiple times that day and they're hospital hopping because they didn't like what one ER told them) where I've refused to transport and gotten the LEOs involved but in the end, I still ended up taking her to the 4th and final hospital in our area where the other police department (two cities in close proximity) decided to take her for EMS abuse. But like I said, only in extreme circumstances.

By protocol I have to tell patients they should be transported to the ER, by ambulance, to evaluate their complaint. If I'm confident in the fact they do not need immediate attention or further assessment I'll lead with "I have to tell you that you need to come to the hospital with me, with that said, this is what I think/know is wrong. This is what you need to do, this is exactly what the hospital will tell you. They may do xxx but I doubt it. I'm more than comfortable with a friend or family member taking you down to the ER or even an urgent care (or in some cases waiting it out at home and going later if it gets worse/doesn't resolve or calling a PCP and setting up an appointment or consulting with them. Now after all of that, if you'd still like to go to the hospital with me I am more than happy to take you there. I will tell you though that you will probably end up in the waiting room. Coming in by ambulance does not guarantee you a room immediately. You're still triaged through the hospital's system no matter your means of arriving at their facility."

It works pretty well, most people are appreciated of the honesty and explanation and opt to go in a personal vehicle or wait it out. The irrational ones generally insist on going in the ambulance.

It really medic dependent, some transport anyone and everyone. Others have a similar approach as me. Currently our transport percentage is up like 10-15% and the general consensus that I've heard is that it's directly related to the influx of new, young, inexperienced paramedics working in the system.
 
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Akulahawk

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Up until a few years ago, Sacramento County Paramedics were essentially stuck with 2 options: transport or the patient refuses care. Sometime in the last 5 years or so, Paramedics can initiate a refusal, within certain guidelines. More often than not, the medics out where I work don't transport, even if the patient called 911 for something.
 

NomadicMedic

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I transport people who need to go, and those that don't can stay home. (this is why we have the ability to obtain a refusal for transport, following treatment.)

For most of you, it sounds like a treat and release isn't an option.

How about a controlled asthmatic, out of their prescribed inhaler? I'll show up, give an albuterol neb and then get a refusal for transport. They don't want to go, nor do they need to go.

Diabetic who's hypoglycemic? I'll give dextrose and leave them home. They don't want to go, nor do they need to go.

A patient with gastroenteritis? I'll give a Zofran. And leave them home. They don't want to go, nor do they need to go.

Now, I don't do this on every call, but I've done all of the above, with the blessing of medical control. If a patient is going to go the ED or see their PCP tomorrow, why should I transport them in an ambulance? Conversely, if they're not feeling well, but it’s not critical, why should I not treat them and leave them at home?
 

ExpatMedic0

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I would say %80-%90 of people we are called to, do not need to go the hospital by emergency ambulance. However, a lot of us are stuck in a system which mandates we transport if the patient request to be transported. Then they just get dumped on the ED, and also charged out the butt for an ambulance ride and an ED visit.
I am hoping and thinking a lot of this may change with health care reform.
 
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DrParasite

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For most of you, it sounds like a treat and release isn't an option.
not for nothing,but it sounds like it isn't an option for you either
How about a controlled asthmatic, out of their prescribed inhaler? I'll show up, give an albuterol neb and then get a refusal for transport. They don't want to go, nor do they need to go.

Diabetic who's hypoglycemic? I'll give dextrose and leave them home. They don't want to go, nor do they need to go.

A patient with gastroenteritis? I'll give a Zofran. And leave them home. They don't want to go, nor do they need to go.
All those are great examples of patients who you treat and then they sign a refusal. Not exactly the same as a treat and release, because if they say they want to go to the hospital, you are still taking them.

Now, I don't do this on every call, but I've done all of the above, with the blessing of medical control. If a patient is going to go the ED or see their PCP tomorrow, why should I transport them in an ambulance? Conversely, if they're not feeling well, but it’s not critical, why should I not treat them and leave them at home?
So have I. Normally my last statement to them is "make sure you follow up with your PMD, or go to the ER if your condition worsens," and that's how almost all my RMAs are documented as well.

As for me, I transport EVERYONE. If they want to go to the hospital, they get transported. If they don't need to go to the hospital, but want to go anyway, they get transported. If they have a condition that could be better treated by their PMD, but they want to go to the hospital via ambulance, they get transported.

I would LOVE to be able to do "provider decided denial of transport," where the provider assesses the patient, and using their own clinical judgement and experience, can advise the patient that they don't need to go to the ER, either before they give an intervention or afterwards, without the need for the patient to refuse service. Backed by your medical director, your operational director, and your agency.

More often than not, our interventions are short term treatments, that need an MD for long term care. And also keep in mind, most of your ER discharge instructors say "follow up with your primary doctor," and many people fail to follow their directions. so do you think they will always follow the directions of a paramedic to follow up with their PMD?
 

NomadicMedic

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As for me, I transport EVERYONE. If they want to go to the hospital, they get transported. If they don't need to go to the hospital, but want to go anyway, they get transported. If they have a condition that could be better treated by their PMD, but they want to go to the hospital via ambulance, they get transported.
Of course, any patient can go to the hospital if they want. Thats why we have an ambulance respond to the calls. In the cases I cited above, they didn't NEED to go and didn't WANT to go. I think the idea of "you called 911, so you're going to the hospital" is ridiculous. As for not following up with their PCP, I'm there to provide immediate care, not baby sitting. There are plenty of patients who sign refusals that promise to follow up with a PCP. should I not allow them to refuse because they may be lying to me?

I would LOVE to be able to do "provider decided denial of transport," where the provider assesses the patient, and using their own clinical judgement and experience, can advise the patient that they don't need to go to the ER, either before they give an intervention or afterwards, without the need for the patient to refuse service. Backed by your medical director, your operational director, and your agency.
I don't make the decision to not transport, the patient does. If I can turn around an immediately correctable issue like bronchoconstriction secondary to asthma or hypoglycemia, the patient absolutely has the right to decide if they want to go or not. That's a "treat and release". I still think they should go, and make that clear ... But I don't drag them to the ambulance just because I "performed an intervention".

Of course, as an EMT-B, you don't have any of those options. so you're stuck transporting everyone.
 

DrParasite

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If I can turn around an immediately correctable issue like bronchoconstriction secondary to asthma or hypoglycemia, the patient absolutely has the right to decide if they want to go or not. That's a "treat and release". I still think they should go, and make that clear ... But I don't drag them to the ambulance just because I "performed an intervention".
No, it's not... it's an RMA post treat. Treat and Release means you perform an intervention, and sent them on their way. RMA post treat means you performed an interveniton, the patient got better, and refused to be transported to the ER. There is a very important different distriction, both from the liability standpoint and from an accountability standpoint. As well as an educational requirement to make that decision.
Of course, as an EMT-B, you don't have any of those options. so you're stuck transporting everyone.
Not quite. If a diabetics sugar is low, and they are concious, I can give them some OJ with sugar. let them check their BGL again. if it's above 70, and they are feeling better, sign here. Do you have your own albuterol inhaler? is it working? your wheezing seems to have subsided. don't want to go to the ER? sign here. Gastroenteritus? Sorry, I can't help you, but you would be better off going to your PMD, or even better, staying home, drinking fluids, and letting your immune system do it's job. Don't want to go? sign here. See, I can do your version of Treat and Release too. A good assessment, some basic interventions, and a recommendation from a professional can make a person feel better.

As a paramedic, you absolutely have more tools at your disposal. And there are situations when I can't help the person, and you can. But don't think that I have to transport everyone just because I'm an EMT. It all comes down to performing a good assessment, performing interventions if you can, and lettign the patient decide if they want to go to the hospital.

Because at the end of the day, if the patient wants to go, you will be taking them to the ER just like i will.
 

Ecgg

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EMT or Medic in todays litigious society you paper work better contain everything in them some in full detail and it would not hurt to get medical control involvement for documentation purposes as well. At this level of the game you need to weigh the consequences of getting sued and would your paper work hold up in court?

How many of you have personal liability insurance? And if you didn't contact medical control because it was routine RMA the lawyer will rip you a new :censored::censored::censored::censored::censored::censored::censored: "is it possible because you are not a doctor and never contacted one that you could not fully comprehend the severity and extent of Mr. so and so condition at the time of contact?"

Yes it's easier to transport than have to play this retarded game. This goes way above "I told them to follow up with their doctor"

You better be recording at least 2 sets of all the vital signs, ekg, bgl, etc.
who called 911 pt? family? bystander?
What is the reason patient is refusing transport?
What is his mental status at the time
Chief complaint
HPI PMH
You offered to take the patient to the hospital of his choosing
You explained the consequences of refusal and dangers associated
Contacted medical control with # etc....

this goes on and on. Much easier to transport then have the potential of getting sued over non sense.


Those that work private, no transport no pay. Do this often enough and may find yourself out of the job.
 
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DrParasite

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How many of you have personal liability insurance? And if you didn't contact medical control because it was routine RMA the lawyer will rip you a new :censored::censored::censored::censored::censored::censored::censored: "is it possible because you are not a doctor and never contacted one that you could not fully comprehend the severity and extent of Mr. so and so condition at the time of contact?"
I do have my own personal liability insurance. Someone suggested it, and for $100 a year, it's well worth it.

As for your comment about always contacting medical control for routine RMA, whaaaaat? Do people really do that? Back when I was in upstate NY, all RMAs needed to be ran by the supervisor, but unless it was an RMA AMA or something serious that you wanted to run by the doctor, it was the supervisor who reviewed it all, who more often than not was just a senior paramedic. I can't speak any other states, but our medical control doctors are ER attendings, and if we were to call them for every single RMA... .well, we would need to have two more doctors dedicated just to OLMC.

I can't see any busy department doing this for every single RMA...... Can you name any large agencies that are doing it?

Even more important, can you cite any law suits where a case was lost becasue the provider didn't call the doctor for an RMA?
You better be recording at least 2 sets of all the vital signs, ekg, bgl, etc.
who called 911 pt? family? bystander?
What is the reason patient is refusing transport?
What is his mental status at the time
Chief complaint
HPI PMH
You offered to take the patient to the hospital of his choosing
You explained the consequences of refusal and dangers associated
Contacted medical control with # etc....
that's documentation 101. If you can't fill out proper documenation, on all your calls, than I don't know what else to tell you.
 

medicdan

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Its routine in my area (at least around one hospital) to call for ALS refusals (diabetic who got d50, svter who broke it with atenolol, etc) and in some cases the docs want to talk to the patients directly...
 

Melclin

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Personal liability insurance? Good god.

You better be recording at least 2 sets of all the vital signs, ekg, bgl, etc.
who called 911 pt? family? bystander?
What is the reason patient is refusing transport?
What is his mental status at the time
Chief complaint
HPI PMH
You offered to take the patient to the hospital of his choosing
You explained the consequences of refusal and dangers associated
Contacted medical control with # etc....
This is documentation 101?

Two sets of everyone? What on earth does that prove? Two BGLs? So their BP is the same five minutes apart..seems like its a bit of a false sense of security.

Why does it matter who called? What does this have to do with the results of your assessment and their desire to be transported?

Choice of destination? Really?
"I'm suing you for not taking me to hospital".
"I tried too. I told you that you were having a massive MI, but you signed this refusal of treatment".
"Yeah but you didn't tell me I could go to any hospital...money please".

Seriously?

Mental status? A person has a sore toe and we're supposed document an whole frigging MSE?

Does being reasonable come into any of this...ever?
 

ExpatMedic0

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Personal liability insurance? Good god.



This is documentation 101?

Two sets of everyone? What on earth does that prove? Two BGLs? So their BP is the same five minutes apart..seems like its a bit of a false sense of security.
Believe it or not the Australian company I worked for required this same exact policy. You know Aspen Medical?
 
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Melclin

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Believe it or not the Australian company I worked for required this same exact policy. You know Aspen Medical?
I don't mean to come across as if I'm saying we're so perfect and what a bunch of clowns you must all be across the Pacific, although reading back now, I can see that I may have.

I'm sure there are many aspects to the way we do things that are silly too.

I hadn't heard of Aspen (although I did some googleing and I have now). In some ways the privately owned component to our healthcare system hides itself a little (or maybe I'm oblivious :p ). I think both because we generally find the notion of private companies being involved in healthcare to be a little distasteful, and because there is little point in most of those companies being known to the general public as they don't provide any services that the average person can use themselves. They're generally contractors to varying degrees of state services.

Incidentally, some people here feel that we are supposed to document at least two sets of vitals to leave people at home here. It certainly isn't set in stone here though. I don't do it and nobody seems to mind. I see absolutely no point in it (with the odd exception) other than to make yourself feel better by seeing two blood pressures that don't scare you rather than just the one.

Patients that have meaningful trends in vitals over a period of five or ten minutes generally aren't the kinds of patients I consider leaving at home.
 

Ecgg

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I do have my own personal liability insurance. Someone suggested it, and for $100 a year, it's well worth it.

As for your comment about always contacting medical control for routine RMA, whaaaaat? Do people really do that? Back when I was in upstate NY, all RMAs needed to be ran by the supervisor, but unless it was an RMA AMA or something serious that you wanted to run by the doctor, it was the supervisor who reviewed it all, who more often than not was just a senior paramedic. I can't speak any other states, but our medical control doctors are ER attendings, and if we were to call them for every single RMA... .well, we would need to have two more doctors dedicated just to OLMC.

I can't see any busy department doing this for every single RMA...... Can you name any large agencies that are doing it?

Even more important, can you cite any law suits where a case was lost becasue the provider didn't call the doctor for an RMA?
that's documentation 101. If you can't fill out proper documenation, on all your calls, than I don't know what else to tell you.
Here you go 18 million awarded in a lawsuit with no telemetry contact for RMA

"The next day Mullings was beset by agonizing pain and numbness and called 911 twice. FDNY medics did not take her back to the hospital."

Read more: http://www.nydailynews.com/life-sty...9m-settlement-article-1.1033059#ixzz2VAomgm2h


http://malpractice.burgsimpson.com/...l-malpractice-suit-against-city-hospital.html


This has nothing to do with your clinical assessments or your knowledge or anything of that nature. I assume you like to sleep under a roof and I also believe your certification provides the income for that so if you enjoy keeping it you better cover all your bases.

There is nothing routine about RMA, and certainly something else could have caused precipitous decline in a diabetic, asthmatic, etc. You don't have the diagnostic tools nor the knowledge to check for that. See in the case the development of sepsis with dg of kidney stone and given painkillers upon discharge.

Additionally if the case does go to court, you will have no defense outside your EMT scope and your paperwork on top of never contacting medical control. You will look stupid and they will most certainly get the compensation that they seek. 2 minute conversation with MD if that gets them to go is absolutely not wasted time. They get paid to answer to phone, utilize your resources.

It's not only documentation 101 those things need to be explained to the patient so he is willingly consenting to them, preferably with a witness present to get both signatures. You also need to show that you made full effort to take him to the facility and consequences of his refusal. Read it carefully patient consent IS NOT A PRODUCT! You need to explain things thoroughly, clearly and objectively.

Like I said it's easier to take them to the hospital. However if you feel confident your 3 months emt course has giving you all the knowledge of all the possible pathologies then certainly do your thing.
 
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Handsome Robb

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Our MDs here would laugh at us and hang up the phone if we called them for anything other than someone with a life threatening condition that was refusing to go. We don't have a dedicated OLMD, we get whatever ERP is the nearest to the charge desk when we call. They're busy, they have bigger fish to fry than dealing with our AMAs. What are you trying to accomplish by contacting them? "Well the doctor said I have to bring you in, you don't have a choice in the matter" does by fly whatsoever.

Like I said, in life/quality of life threatening situations I'm all for calling an MD and having them converse with the patient but that's about the only time. Only other time I have to call is of someone meets state trauma criteria by physiological component or injury and they want to go to a different hospital or no hospital at all but I've never run into that problem.

Yes I do carry personal liability insurance.
 
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jefftherealmccoy

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Does being reasonable come into any of this...ever?
If you're talking about a patient being reasonable or the lawyer who is going to sue you, no. There's no reason anymore. Everyone in this country is sue happy and therefore we all have to cover our asses. Hence the trend of convincing people they need to go to the hospital for simple stupid things.

To those of you who have procecuted someone for EMS abuse, how is that done? We had a lady once that called pretty much every day. She was no longer accepted as a patient in any ER within 20 miles of her house because she was there so often. I went on her twice within a 12 hour period and we caught her dashing to get into her bed when we walked in the door. Our chief had a meeting with our medical director, the city attorney, the local ER staff, and some reps from law enforcement and they concluded that when she called and wanted to go, we took her. Luckily she moved after a few months.

And to those working outside the US, is there as much of a risk of getting sued for something like this? Are there any laws protecting from lawsuits that arn't obvious or gross neglegence?
 
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