Who is the customer/You make the call

So; a scenario:

You respond to a local urgent care center where a Nurse Practitioner (there is no physician on staff) shows you to a middle-aged male who came in complaining of chest pain. The NP informs you that she performed a 12-lead, but didn’t see anything “really too wrong.” She also informs you that she has already called report to Roundthecorner Medical Center, and they are awaiting your arrival.

Roundthecorner Medical Center is one mile away.

After loading the patient in your ambulance, you perform your own 12-lead and almost fall over when you notice the humongous ST-segment depressions in the anterior, lateral, and septal leads.

Roundthecorner Medical Center does not perform interventional catheterization. They can perform caths, but can’t place stents. (Don’t get me started on that one.)

St. Elsewhere is 18 miles away, and they have the whole host of cardiology services.

For the sake of argument, your patient is stable enough to make the trip to St. Elsewhere. I’m not too interested in treatments, just the next decision to be made.

Your company policy says you must transport the patient to the hospital that the customer (in this case the NP) selected, and you are not supposed to even attempt to persuade the patient to choose another hospital.

Do you:

A: Take the patient to Roundthecorner Medical Center

B: Inform the patient that he is having “the big one” and transport him to Roundthecorner Medical Center

C: Inform the patient that he is having “the big one” and suggest he goes to St. Elsewhere

D: Suggest to the patient that he go to St. Elsewhere as opposed to Roundthecorner Medical Center, without telling him why.

 

I’m interested in reading your choice, and why you made that choice.

I’ve always held that the patient is the true customer, and the one we should be most focused on. I’ll let you all know what I would choose some time in the next few days.

Comments

  1. Azirishmedic says:

    I personally would inform the patient that I am seeing some issues on the monitor that make me think that he should go to a hospital that could look at the issue and deal with it right away. I would explain that he could go to the nearest facility but runs the risk of having to ride in the back to another hospital if the changes I see are also found in the hospital. I would also explain that this is a precautionary idea on my part but would be in his best interest. I agree with you CCC that the patient is the ultimate customer, and this is something that I used to get dinged for by supervisors all the time.

  2. As far as im concerned the patient is going to get the bill so technically they’re the customer. And a customer cant make an informed decision without all the info. This is exactly what I would say; “Sir I don’t wish to alarm you but based on this ekg and my years of experience as a paramedic you seem to be having a pretty large heart attack. Now, if you want us to take you to RMC we will. It is company policy to take patients where they want to go, however just so you have all the facts you should know RMC doesn’t have an interventional cath lab (and explain what that means). St. E’s however does. If that is where you wanted to go we’d be more than happy to take you. I’m not allowed to favor one hospital over the other and I want you to make the best decision because hey it could mean your life”

    But I tend to get in trouble with my bosses a lot so I might not be the best person to ask.

    You cant MAKE the guy go somewhere he doesn’t want to and you cant force him to be smart but I believe you can stack the deck in your favor.

    Do you guys have a STEMI system?

    • We do have a STEMI system, though it hasn’t solved problems like this.

      I tend to get in just enough trouble that my bosses roll their eyes without filling out paperwork. They take phone calls about once every two weeks about me.

  3. In my neck of the woods you must transport to the most appropriate facility. I run into this exact senario in the rural area that I run in. The hospital can perform a cath but cannot place stents or do cardiac surgery however they are the closest “cardiac center” and we must transport any cardiac pt there as they are closer than anywhere else. So in my area we dont have a choice but to transport to roundthecorner medical center. If we are 30 to 45 min away and we have a STEMI or other MI we often opt to fly the pt so they can get to St. Elsewhere for the higher level of care.

    In the situation posted above if they have the option and the PT can choose where to go I would advise them of thier options and of the different hospitals capabilities and let the pt make an informed decision about their own healthcare. However with that said if the pt should happen to crash between Roundthecorner Health Center and St. Elsewhere you will probably be handing in your uniforms and finding a new job because you didn’t transport to the closest appropriate facility.

    • JB;

      If your hospital cannot place stents or open chests, how are they considered a “cardiac center?” Not sarcastically, but seriously.

      Let us take your scenario of the patient crashing between RMC and St. E. If the patient did choose to go to St. E, and crashed on the way, couldn’t it be said that he would have crashed inside RMC? And we have already established that RMC can’t perform the needed intervention.

      • CCC,

        They are considered to be a STEMI center and are rated by one of the not so accredited health score systems to be a top cardiac hospital in the area. How they got this status I have no clue since I think they send out more cardiac cases than they actually help there.

        There are quite a few places around where I work that dont give the pt a choice of where they go. Like the county where I work says we will be happy to take you to RMC and if you would like to go to St E we will be happy to get you in the car and your family can drive you. There are a few instances where this is not a factor like certain child cases, trauma, etc. Since RMC is a “Cardiac Center” they are considered to be definitave care and should be transported there to be stabalized then can be sent out if needed for the care they actually need. Its just a bit messed up but thats the way they do it.

        With that being said there are quite a few agencies that boarder our county that will allow the pt to make the choice of where they would like to go but there are many rural areas here that have 1 hospital that they transport too without any options to the Pt.

  4. I have to go with the premise that the patient is the ultimate customer and the NP is an ‘interested bystander’. I am fortunate in that where I work, if I do what is in the best interests of the patient, and I can remotely justify it with a somewhat lucid thought process, I am in the clear.

    Plus, in my not-so-subtle way, I would just come out and tell the patient “We can go to Roundthecorner, but they cannot handle what is going on with you, they are going to have to transfer you anyway, and the delay could very well be fatal”. I have had to do that before, and I try to break it down in terms they can understand- “A blood vessel on your heart is clogged (that’s these lines on this EKG mean) and you need at least one stent to survive, and they cannot do that at Roundthecorner. You have to go to St Elsewhere to get that, and waiting for Roundthecorner to transfer you could kill you, so let’s cut our the middle man, whaddya say.”

  5. Agree with the above posters. What protects me legally is that in a STEMI situation, my medical control is the closest PCI center- not the closest ER.

    Wouldn’t stop the company from firing me if they wanted to, at which point my ability to get my job back is proportional to how much money I have for a lawyer to make my previous point for me to the Labor Board.

  6. Midwest Medic says:

    The patient goes to St. Elsewhere unless some sort of compelling circumstance dictates otherwise. The NP isn’t the decision maker in the situation. It’s between the medic and the patient to decide where he goes. Also, if standing medical orders dictate the decision, it should override company policy. It’s about what’s best for the patient, and what care he NEEDS, not what makes Local Urgent Care happy.

  7. Flash Larry says:

    The issue here is one of informed consent. In my state, a patient has the absolute right to be transported to the facility of his choice with one exception.

    The exception, which bears discussion: The regulations state that if the EMS service medical director has established a “reasonable distance” for transports that the medical director can override the patient’s wishes if the patient wants to go further than the “reasonable distance.” The intent of the regulation was to prevent a patient from demanding transport to a distant city. It is my understanding that the medical directors of some services are establishing “reasonable distances” that insure that patients go to particular hospitals of their choice. The matter has not yet been litigated but at some point, it will be and then a jury will determine what constitutes a reasonable distance. That will be interesting both in the courtroom and in the newspapers.

    I don’t know what the laws are in your states but here it appears that the ambulance service rule is denying the patient the right to informed consent, which is actionable at law in several ways. As all of you know, patient consent is required before you treat them. Under the law of my state, if a mentally functioning patient is informed as to what you’re doing and doesn’t express opposition, then consent is presumed (this arose out of a patient who did not expressly consent but did not object to care and then turned around and sued for failure to obtain consent. The appellate courts ruled that the plaintiff should have expressed opposition at the time of care rather than suing later).

    However, the second part of consent is that it must be informed. The patient must be informed of his condition and risks of treatment. Therefore any rule that states otherwise is contrary to law.

    Therefore, this patient should be informed that his EKG shows what may be an imminently serious cardiac condition that is usually effectively treated by a particular procedure, be told what the different facilities can and cannot do, what your recommendation is and what you’d do with another patient in the same condition for whom you had not received specific orders. It is not necessary to tell him that they screwed up the 12-lead but that yours shows something different than what they got when they took it and things might have changed (they do, actually).
    The patient is then able to make his own informed choice as to where he should go.

    It’s not necessary to suggest, then or later, that the transferring facility made any errors. The most important thing is that your documentation supports your decision.

    If you do not proceed in terms of informed consent, you and your company (under the doctrine of respondeat superior) could be held liable at law for any injury to the patient caused by taking him somewhere he didn’t want to do or by not informing him of his conditions and the destination options. As well, the paramedic could be in danger of losing his license for violating state regulations. I assure you, if it comes to a court case or administrative hearing, the ambulance service will NOT send in their owners and managers to say, “It’s not his fault, we told him to do that.” They will say, “We never, ever, ever would tell one of our employees to do anything that would be detrimental to patient care or in violation of the law.”

    Which brings me to a question, CCC? Is that policy that you specified actually in writing anywhere, or is it word of mouth? (see above paragraph if it’s word of mouth or less than explicit)

    If, on the other hand, you transport the patient to the appropriate facility (18 miles away) WITH the patient’s informed consent, and most especially if you are proven right and the company takes an adverse personnel action against you, the company may be liable at law in a lawsuit brought by the employee for creating a policy that violates state law. I can also assure you that public opinion would not be on the side of the company either, if it became public. Nor, I think, would the patient support the company’s adverse personnel action. Nor, I think, would the transferring office (who must have some reason for wanting them transported to a particular facility) be interested in having it made public.

    Always, always, always do that which is in the best interests of the patient and what complies with the law.

    One of my more famous moments was when I was dispatching one day (yes, I did that too) and with all my units tied up, had a walk-in to the station having a possible heart attack. After warning my units to hold their traffic, I put the patient on high-flow oxygen, went back in and called a competing private service to come get the patient out of our main station. It was the only option I had. It was in the best interest of the patient. Fortunately my boss at the time ever only asked one question when you went outside the box, and that was exactly that. Was it in the best interests of the patient? As he said, every time, “Patient care comes first.”

    That’s the way it should be.

    • Thanks for all that, Flash. I’ll respond in a new post just as soon as I can.

      • Flash Larry says:

        I probably should state here that I am not a lawyer or the son of a lawyer. I did, however, spend 30 years of my life working with the law and as a result I got interested in the law for my parallel EMS career. I have done a lot of reading. Many of our questions can actually be answered from already-existing case law and that’s what I rely on: that, and how legal thinking works. You start with what you know, which is the official code, then look at the appellate decisions that define the meaning of that code.

        When presented with a case such as this one, I automatically ask, “What does the official code of the state actually say about patient transport?” followed by agency rules and regulations and then case law. That’s where my opinion above derives.

        Most of you have had EMS law at one level or another in your EMS classes and therefore have been exposed to the idea of duty, standard of care, liability, and negligence and gross negligence. You will therefore remember that violating the law is generally considered to be per se gross negligence in which the burden of proof transfers from the plaintiff to the defendant (you).

        • With all due respect to my EMT and Paramedic instructors, “EMS law” was not a subject that was even remotely discussed.

          “Don’t touch people who don’t want to be touched. Get signatures. Document” was the extent of those lectures.

  8. Perhaps I missed it mentioned, but another option would be to say a few words to the NP. it wouldn’t take too long to hop out of the rig, tell the NP that you see something new & interesting on the ECG, and that the best course of action is bypassing the non-PCI center. It shouldn’t take too long to say this, and probably avoids most of the controversy.

    It’s hard to imagine that the same clinician who is calling you for cardiac concerns would object to upgrading the acuity level. Heck, you might be validating their clinical impression that they didn’t feel comfortable sharing if their ECG said “normal!”

  9. Option E, please. I have done similar things in the past. Go back in (or send your partner) to talk to the NP and bring them out to the unit. Explain that the 12-lead is now showing something different, and that interventional cath is a high probability and see if he/she will agree to change destinations as it is more appropriate. You could always put the decision in the hands of the ER doc or whomever acts for your online medical control, and let them make the decision for you. Then you “err” on the patient’s behalf and the doc makes the decision, not you. With the NP and patient present (and/or doc on the radio or phone), you have a council. The patient will be able to make the informed decision for themself, based on the advice of several health professionals. Advocacy may not turn out the way you think it should, but at least you will have put in your due diligence, and no one can say the consent was uninformed, and you’ll have witness and maybe recorded lines to back you up.

    You can explain risks as, “The risk of going to RMC is that you could go in for diagnostic cath, then they find something they must act on, but will then have to send you to St. Elsewhere to complete the procedure. This could result in worsening your heart problem, a more risky transport by ambulance with lots of IV’s and an IABP, and extensive doctor, hospital, ambulance, and surgery bills that would have otherwise been saved if you just gone to St. Elsewhwere.”

    Tough call for you. It’s easier for us armchair quarterbacks who have the benefit of hindsight.

    • Thanks for your input. I certainly like your answer the most. I never thought to bring the NP back to the ambulance, or to go back inside (or to send my partner) and I am thankful you and the others have given that solution.

      Answer “E” it is, from now on.

      Then, we can all make the decision together, as a team.

      Genius, I say!

  10. We’re an emergency medical service, not UPS. The patient isn’t just another “package” that we ship however the sender wants. The patient (who ends up paying the bill) is the client. STEMI protocols would be your saving grace here. Otherwise, informed consent is your friend.

    I would also have my partner run in to tell the NP that there’ve been EKG “changes” (in all likelihood, they may have missed it in the first place… but let’s be diplomatic) and the patient is now having a massive MI. Being kept in the loop will usually result in fewer complaints and happier contracted entities. They might even be able to help catch something your not… like a history of a ventricular aneurysm with chronic STE or ERP.

    A little bit of tact and grease on the wheels goes a long way.

  11. Medical Control contact for diversion to appropriate facility.

    If we go to, sorry I forgot your name for the nearest, St Closest and he needs to be transferred, that’s $5500 for the evaluation and another possibly $1700+ if they call a CCT car.

    If the patient truly is your customer (they’re not) but if they are you are doing them a huge savings by transporting directly to the PCI center. That is, of course, if your simple assessment (no labs) and the NP’s lackluster glance are accurate as to the extent of the interventions required.
    This is the exact situation STEMI programs with 12 lead transmission were designed for.

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