you'd discourage the pt from being transported?
That is absolutely incorrect and misleading. I would not be discouraging them from being transported, but giving them a chance to make an informed decision. This means doing a full patient assessment (including a full head to toe like you did in EMT/paramedic school), and then informing the patient what I see, what I am thinking, potential problems, the pros by going by ambulance, what I will likely do during this transport if anything at all, and then the cons of going by ambulance (mainly financial).
When I do refusals, I go over each vital signs, what is taught as normal (eg "Your heart rate was 72. A normal heart rate is 60-100."). I would also go over things each thing I was looking for (eg "I looked for signs of a shock. Example signs are low blood pressure and a fast heart rate. Your blood pressure was 150/80, which above textbook perfect 120/80, and your heart rate was 72, which is within normal limits. I do not suspect shock. I looked for signs of spinal injuries, but you denied pain in the neck and back, and I did not see any obvious signs of a broken bone when I looked and touched your back."). Things like that. This would lead me to tell them that the safest option always is going by ambulance to the emergency department, that you'd have a paramedic nearby if your condition changed, and you'd get seen by a physician. I would tell them that as a paramedic, I trained to look for and treat immediate life threats, but that I cannot medically clear them. I cannot guaranty that everything is OK. I would tell them some problems might not be obvious right now, that they could slowly develop, and potentially become disabling or even deadly. Common examples I give is fractures that I cannot see because we do not have an x-ray in the ambulance, that they could have a slow/small bleed in the head that isn't causing any neuro deficits right now, but could in hours from now, or that they could have a small internal bleed somewhere else in their body that could eventually lead to shock. I would then say that right now, if I transported you, I do not anticipate that I would start an IV on you, I wouldn't give you any medications, and that I would expect to just monitor you and give you a ride. I would tell that based on my report to the hospital, they may potentially have me put them in the waiting room, that an ambulance ride does not guaranty that they will get a room right away at the hospital. I would tell that ambulance transport without insurance is usually >$2,000 (we don't know exact price because it depends on the mileage, and the prices I remember are old ones since they don't give us updated ones (they used to have us carry a sheet with all the price of each thing we charge for, but they stopped doing that)), that I cannot guaranty their insurance will cover it, and I don't know what their deductible is or co-pay is even if the insurance does cover it. I always make sure to say to patients that I consider low risk, ones who have no complaints that just want to be checked out, patients who have what I consider to be a minor injury (eg a cut on the toe, which I just got 2 days ago), is that "low risk does not mean no risk." I've always like to remind people of that. I tell them I am more than happy to transport them, they are also welcome to find alternative means like have a friend/family pick them up, use Uber, and sometimes tell them that they could call their PCP or go to urgent care instead. If they end up signing the refusal, I remind them they can call 9-1-1 if they even changed their mind about ambulance transport, even if nothing changed, that's OK to call us. I tell them our ultimate goal is that they are safe and healthy. I definitely encourage them to call 9-1-1 if their condition changes, and I sometimes things to look out for like telling car accident patients that nausea, dizziness, and feeling disoriented could be sign of a brain bleed, and ask them not to wait that out.
It's important that our patients make an informed decision. We shouldn't be so light like "Ah, nothing will happen", but they should know their odds, and it should be up to them if it is worth it to them to chance it, find another means to see a physician, or if they'd rather feel safe paying a lot of money. It think it is absolutely unreasonable to use a lot of fear to convince the patient to spend a lot of money and waste their personal time to go to the hospital when they likely don't need to even go. I think it's OK to tell the patient that there is even a risk of dying, but the way a lot of providers use it, their tone, they make it sound like it is 50/50 rather than like <1% (I don't give statistic, but just that sound like "OK, you are signing here that you know you can die, it is your fault if you die, here you go."). I go over everything and try to help them understand the situation and what can happen. Before I used to do this, I would take patients to the hospital, and we used to dump them in triage/the waiting room. I felt bad. Like I said before, I push to assess everyone involved on scene, full thorough assessment, because my brother didn't get that when he got into an accident, and my brother was genuinely worried that something was wrong with him, but was too scared to call 9-1-1 to look weak/whiny.
Is this wrong? Should I be telling my toe cut patient that I had a couple of days ago he can die so he probably should go to the hospital with us? Should I tell that truck driver whose chief complaint is "shaken up", no complaint of pain, normal vital signs "You can die so you probably should go to the hospital with us." That to me is not truly informed decision making, misleading, and bad paramedicine.
