Physician vs. Patient vs. Paramedic

Chest pain at an urgent-care facility. A female in her 40s, according to the dispatch notes. For all we know, this could be a 93 year old male with a bunion. Silly call takers.

This time, they got it right.

“She is 43,” the physician on staff informs us. “Her chest has been hurting since 11 o’clock last night, and she needs to go to the emergency room. Her EKG is abnormal” he goes on, as he hands me a 12-lead.

It’s a sinus rhythm in the 70s with not a thing wrong. I couldn’t draw one better with a ruler and 6 hours of practice. But it says “Abnormal EKG” at the top.

I guess ‘reading EKGs’ is the same as ‘reading the words at the top of the EKG’ to some people.

“Hi, I’m C from the ambulance, how are you doing today?” I ask the very matronly, middle-eastern appearing woman in the room. I notice she is fully clothed, and wonder how an accurate EKG was obtained through a sweater, long sleeve shirt, and bra.

I suppose she could have gotten dressed after disrobing, but I doubt it.

“I’m fine, I guess. What are you guys doing here?” She looks genuinely puzzled.

“Well, the doctor called us and thinks you should go to the emergency room because your chest hurts.”

“I threw up 5 times last night and it made my throat burn. Where did he get chest pain? I don’t want to go to the hospital.”

The doctor walks in the room; “Yes ma’am, these nice ambulance people are going to take you to the hospital to make sure everything is alright.”

“But I don’t want to go to the hospital!” she retorts.

“I really think it is in your best interest” the doctor replies as he walks out of the room.

She acquiesces to the suggestion, but seems hesitant. I’m not too concerned just yet.

“Let’s move you into the ambulance, and get a few things done, and just go from there.”

After loading her in the ambulance, and several uncomfortable moments while she undresses from the waist up, with her modesty maintained, of course, her EKG still looks better than mine. Try and try, I can’t find anything wrong with it. Her vital signs are more than fantastic. Excellent, actually.

We determine that she vomited several times during the night after eating sushi and having drinks with her friends. Her throat and nostrils were burning, but her pain was gone now. Drinking milk or cold liquids seemed to help the situation. Then she says the magic words:
“I don’t want to go to the hospital.”

We do the whole rigmarole with the refusal paperwork, and she signs the form, saying she will go to the hospital if she ever needs to, but will never come back to this place.

I don’t blame her.

She gets dressed again, and steps out of the ambulance, walks to her car, then drives off. After we rearrange the ambulance and put the equipment back, I step out of the side door, to be met by the same doctor from inside with a very disapproving look on his face.

“Just what do you think you are doing?”

“Getting in the ambulance, and going in service” I reply. “The patient didn’t want to go to the hospital.”

“She has to go, I’m the doctor, and that’s why I called the ambulance.”

“Maybe if you had explained to her that you wanted to go to the hospital by ambulance, she could have told you she didn’t want to go, and you wouldn’t have wasted her time.”

Paramedics-1 Urgent Care-0

Comments

  1. Flash Larry says:

    This sounds like the kind of thing I might have done at one time or another but there is no way that we could get away with it now. The patient is not our customer. The person who calls us with business is our customer because they’re the source of us getting money.

    If one is going to have to go to the emergency room anyway, best to just start there and avoid such places.

    • If a pt is C/a and O, we can not take them against their will.

    • I believe the correct answer is that the person being saddle with the bill is the customer. The doctor here has no financial responsibility to this call. The Doc did not place her on a hold, so there is no right to take her against her will.

      I believe that is has become too easy for a clinic to pass the patient off and not have to treat or diagnose. After all, they already got to charge for an office visit.

  2. What was the exact message on the ECG? Can you post it? I’m not 100% sure whether to celebrate your actions or be concerned.

  3. Justin D. says:

    Flash- Sorry to see that you are not a patient advocate. No matter what the patient is always your customer. I’m not saying that you wouldn’t get in some sort of trouble from your supervisor but it’s sad to see some in EMS think that way. If you are getting a full legal informed signed refusal, and you are following all of your local protocols (mine include calling Med Cntrl in this situation) , there is no reason to take people against their will.

    • Justin; I don’t believe that Flash Larry thinks the patient isn’t our customer. I believe he was just attempting to use sarcasm to make his point.

      I agree that the problem nowadays is the failure to see the patient as the customer, and to cater to the callers instead.

      • Flash Larry says:

        CCC is right. My point was sarcasm though sometimes people take such things too literally. Certainly, no one can transport a competent patient against her will nor would I attempt it. My point was that I can’t make those kinds of comments to a customer (e.g. staff at the transporting facility).

        As far as medical control is concerned, they are not able to override a competent patient’s right to decline transport. If the physician thinks that the patient may not be competent, he would have to prepare the proper legal paperwork to have that patient declared incompent and then transport could be discussed.

    • It does raise the question of what you’d do if med control wanted you to transport the patient….

      • Here in South Carolina(or a least at the County Service I work at), if a pt is C/a and O and makes there own medical decisions, we can not take them against there will. If you do, you can be arrested for kidnapping. No medical control order is worth that. I do want whats best for my pt. If it was a situation I felt the pt really needed to go, I would do my best to talk them into it, But ultimately it is the pts choice. But I would document thoroughly that the pt adamently refused against strong medical advice. It is fustrasting though when somebody who really needs to go, wont.

        • Rebecca, do you have either statute or common law citations for that? I’m not disagreeing, because the patient generally has the last word. However, in over 30 years working EMS I have never, ever, heard of anyone being arrested or even sued for taking someone to the hospital against their will.

          • There was a case of this in the news not long ago. Regardless, I think once we start asking about our exact legal liability, we’re going down the wrong path; forcing any medical intervention upon a competent person who has explicitly refused it is obviously wrong.

  4. Flash Larry says:

    Legal codes of the state of your practice will specify such things as who can and cannot consent for a patient, how a patient can be declared incompetent to decide for himself, who can make that decision and authorize transport and how that authorization has to be accomplished. There may be, as in our state, further controlling regulations by the EMS governing agency that is outside of the civil code.

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