Trends

March 27, 2004

Salvador, understand that this post does not mean to be a reflection on

you personally.

I see 2 problems that really bother me.

1) the possibility that any service, no matter if they are private,

municipal, etc., would deny treatment, until such time as they had the

patient to a point where they could not or would not be able to refuse

treatment

2) the fact that a service states that you will be " turned in to TDH for

decert procedures by the MD for practicing medicine without a license "

for explaining and giving the patient the ability to decide on their own

medical care.

I am quite sure that Wes and/or Gene will chime in if I am wrong, but I

have to say with regards to the latter " That's the biggest line of s***

I have heard for a long time " .

Mike

Re: TRENDS

Hint: Load and Go. Initiate treatment in the bus while enroute. Most

of

the time we tell them they can sign out AMA at the ER on arrival.

Re: TRENDS

In a message dated 3/27/2004 2:33:05 PM Central Standard Time,

mpate1104@... writes:

I'm a little curious as to how you " mandate " that these patients be

transported. If you have an alert, well-oriented adult patient who

has

been

informed

of the risks (and who may very well understand his illness just as

well,

or

better, than you do), and that patient chooses to not go to the ER,

how do

you

" mandate " that he go?

Maxine Pate

----- Original Message -----

From: Salvador Capuchino Jr

What if your D50 pt's BS drops again after you leave? What if your

Epi

pt

goes into PSVT or worse? Our company mandates that everyone who

receives

a

medication be transported to ER for f/u care/tx.

If you have an alert, oriented pt who wants to refuse and hasn't been

given

any meds, then let them. A lot of Medical Directors mandate as

Salvador

says

that your pt understand that if they're given meds, they're taking a

ride.

Because it's their license, they don't want to leave that decision

making

to

you.

For them Meds=Transport.

March 27, 2004

Salvador, understand that this post does not mean to be a reflection on

you personally.

I see 2 problems that really bother me.

1) the possibility that any service, no matter if they are private,

municipal, etc., would deny treatment, until such time as they had the

patient to a point where they could not or would not be able to refuse

treatment

2) the fact that a service states that you will be " turned in to TDH for

decert procedures by the MD for practicing medicine without a license "

for explaining and giving the patient the ability to decide on their own

medical care.

I am quite sure that Wes and/or Gene will chime in if I am wrong, but I

have to say with regards to the latter " That's the biggest line of s***

I have heard for a long time " .

Mike

Re: TRENDS

Hint: Load and Go. Initiate treatment in the bus while enroute. Most

of

the time we tell them they can sign out AMA at the ER on arrival.

Re: TRENDS

In a message dated 3/27/2004 2:33:05 PM Central Standard Time,

mpate1104@... writes:

I'm a little curious as to how you " mandate " that these patients be

transported. If you have an alert, well-oriented adult patient who

has

been

informed

of the risks (and who may very well understand his illness just as

well,

or

better, than you do), and that patient chooses to not go to the ER,

how do

you

" mandate " that he go?

Maxine Pate

----- Original Message -----

From: Salvador Capuchino Jr

What if your D50 pt's BS drops again after you leave? What if your

Epi

pt

goes into PSVT or worse? Our company mandates that everyone who

receives

a

medication be transported to ER for f/u care/tx.

If you have an alert, oriented pt who wants to refuse and hasn't been

given

any meds, then let them. A lot of Medical Directors mandate as

Salvador

says

that your pt understand that if they're given meds, they're taking a

ride.

Because it's their license, they don't want to leave that decision

making

to

you.

For them Meds=Transport.

March 27, 2004

Mike, I agree wholeheartedly, but I have bills to pay. They have told us that

by any medic TELLING A PT THAT THEY DO NOT HAVE TO GO, is practicing medicine

without a license. Whether it is or is not, I do not know for a fact. And if

the MD agrees with it, then I have no choice but to either find another service

or do as I am told. And there may be a few times when we may say it, but they

are few and are kept to a minimum.

Re: TRENDS

In a message dated 3/27/2004 2:33:05 PM Central Standard Time,

mpate1104@... writes:

I'm a little curious as to how you " mandate " that these patients be

transported. If you have an alert, well-oriented adult patient who

has

been

informed

of the risks (and who may very well understand his illness just as

well,

or

better, than you do), and that patient chooses to not go to the ER,

how do

you

" mandate " that he go?

Maxine Pate

----- Original Message -----

From: Salvador Capuchino Jr

What if your D50 pt's BS drops again after you leave? What if your

Epi

pt

goes into PSVT or worse? Our company mandates that everyone who

receives

a

medication be transported to ER for f/u care/tx.

If you have an alert, oriented pt who wants to refuse and hasn't been

given

any meds, then let them. A lot of Medical Directors mandate as

Salvador

says

that your pt understand that if they're given meds, they're taking a

ride.

Because it's their license, they don't want to leave that decision

making

to

you.

For them Meds=Transport.

March 27, 2004

,

I have to add a couple of things that concern me also...

1. I am not paid to " transport patients " . I am paid to take care of patients and

provide them with a standard of care. This sounds like fine management at work

again.

2. Scaring patients is one of the worst things I have seen on this list in a

long time. (Now that is saying a lot)

You make a really great point.

Neil

Re: TRENDS

In a message dated 3/27/2004 2:33:05 PM Central Standard Time,

mpate1104@... writes:

I'm a little curious as to how you " mandate " that these patients be

transported. If you have an alert, well-oriented adult patient who

has

been

informed

of the risks (and who may very well understand his illness just as

well,

or

better, than you do), and that patient chooses to not go to the ER,

how do

you

" mandate " that he go?

Maxine Pate

----- Original Message -----

From: Salvador Capuchino Jr

What if your D50 pt's BS drops again after you leave? What if your

Epi

pt

goes into PSVT or worse? Our company mandates that everyone who

receives

a

medication be transported to ER for f/u care/tx.

If you have an alert, oriented pt who wants to refuse and hasn't been

given

any meds, then let them. A lot of Medical Directors mandate as

Salvador

says

that your pt understand that if they're given meds, they're taking a

ride.

Because it's their license, they don't want to leave that decision

making

to

you.

For them Meds=Transport.

March 27, 2004

You know, they way all of you all are talking, it makes me want to go work where

you all do. Guys you have to understand, as you say Neil, the wonderful

management at work again. But I guess most everyone has learned to put up. We

used to complain at company meeting when we had them, but they fall on deaf

ears. Remember, private companies are in it for the money. No income, no pay.

Re: TRENDS

In a message dated 3/27/2004 2:33:05 PM Central Standard Time,

mpate1104@... writes:

I'm a little curious as to how you " mandate " that these patients be

transported. If you have an alert, well-oriented adult patient who

has

been

informed

of the risks (and who may very well understand his illness just as

well,

or

better, than you do), and that patient chooses to not go to the ER,

how do

you

" mandate " that he go?

Maxine Pate

----- Original Message -----

From: Salvador Capuchino Jr

What if your D50 pt's BS drops again after you leave? What if your

Epi

pt

goes into PSVT or worse? Our company mandates that everyone who

receives

a

medication be transported to ER for f/u care/tx.

If you have an alert, oriented pt who wants to refuse and hasn't been

given

any meds, then let them. A lot of Medical Directors mandate as

Salvador

says

that your pt understand that if they're given meds, they're taking a

ride.

Because it's their license, they don't want to leave that decision

making

to

you.

For them Meds=Transport.

March 27, 2004

Must be heaven in your region or companies. No management to tell you how to do

your job as far as refusals/no transports go. And I guess I will end this topic

here before I get retaliated against by anyone from the company who may be

following along.

Salvador Capuchino Jr

EMT-Paramedic

Valley EMS

www.valleyems.com

Re: TRENDS

In a message dated 3/27/2004 2:33:05 PM Central Standard Time,

mpate1104@... writes:

I'm a little curious as to how you " mandate " that these patients be

transported. If you have an alert, well-oriented adult patient who

has

been

informed

of the risks (and who may very well understand his illness just as

well,

or

better, than you do), and that patient chooses to not go to the ER,

how do

you

" mandate " that he go?

Maxine Pate

----- Original Message -----

From: Salvador Capuchino Jr

What if your D50 pt's BS drops again after you leave? What if your

Epi

pt

goes into PSVT or worse? Our company mandates that everyone who

receives

a

medication be transported to ER for f/u care/tx.

If you have an alert, oriented pt who wants to refuse and hasn't been

given

any meds, then let them. A lot of Medical Directors mandate as

Salvador

says

that your pt understand that if they're given meds, they're taking a

ride.

Because it's their license, they don't want to leave that decision

making

to

you.

For them Meds=Transport.

March 27, 2004

Must be heaven in your region or companies. No management to tell you how to do

your job as far as refusals/no transports go. And I guess I will end this topic

here before I get retaliated against by anyone from the company who may be

following along.

Salvador Capuchino Jr

EMT-Paramedic

Valley EMS

www.valleyems.com

Re: TRENDS

In a message dated 3/27/2004 2:33:05 PM Central Standard Time,

mpate1104@... writes:

I'm a little curious as to how you " mandate " that these patients be

transported. If you have an alert, well-oriented adult patient who

has

been

informed

of the risks (and who may very well understand his illness just as

well,

or

better, than you do), and that patient chooses to not go to the ER,

how do

you

" mandate " that he go?

Maxine Pate

----- Original Message -----

From: Salvador Capuchino Jr

What if your D50 pt's BS drops again after you leave? What if your

Epi

pt

goes into PSVT or worse? Our company mandates that everyone who

receives

a

medication be transported to ER for f/u care/tx.

If you have an alert, oriented pt who wants to refuse and hasn't been

given

any meds, then let them. A lot of Medical Directors mandate as

Salvador

says

that your pt understand that if they're given meds, they're taking a

ride.

Because it's their license, they don't want to leave that decision

making

to

you.

For them Meds=Transport.

March 27, 2004

I agree, and I believe Salvador does too, and this brings us back to one

of the main points of this thread in the first place.

Different types of services *do* provide different levels of care. The

service that Salvador works for put more emphasis on the bottom line, as

many private services will, than on the actual needs of the patient. The

services I work for (knock on wood) place more emphasis on the needs of

the patient, whatever they may be, than the actual bottom dollar. Is

that out of fear of litigation? Perhaps at the top administration level,

but I do know that my Directors on down would rather you care for the

patient and explain a fiscal loss on the call, than provide care other

than that which the patient needs for the sake of a financial gain.

FD's aside, the level of care that you receive CAN BE based upon the

type of service that you work for, regardless of the abilities of the

attending medic.

Now, before I become something akin to Joan of Arc, and get burned at

the stake, let me add this disclaimer.....

This is not true with *every* private service, nor with *every* FD.

Whew...

Mike

Re: TRENDS

,

I have to add a couple of things that concern me also...

1. I am not paid to " transport patients " . I am paid to take care of

patients and provide them with a standard of care. This sounds like fine

management at work again.

2. Scaring patients is one of the worst things I have seen on this list

in a long time. (Now that is saying a lot)

You make a really great point.

Neil

Re: TRENDS

In a message dated 3/27/2004 2:33:05 PM Central Standard Time,

mpate1104@... writes:

I'm a little curious as to how you " mandate " that these patients be

transported. If you have an alert, well-oriented adult patient who

has

been

informed

of the risks (and who may very well understand his illness just as

well,

or

better, than you do), and that patient chooses to not go to the ER,

how do

you

" mandate " that he go?

Maxine Pate

----- Original Message -----

From: Salvador Capuchino Jr

What if your D50 pt's BS drops again after you leave? What if

your

Epi

pt

goes into PSVT or worse? Our company mandates that everyone who

receives

a

medication be transported to ER for f/u care/tx.

If you have an alert, oriented pt who wants to refuse and hasn't

been

given

any meds, then let them. A lot of Medical Directors mandate as

Salvador

says

that your pt understand that if they're given meds, they're taking a

ride.

Because it's their license, they don't want to leave that decision

making

to

you.

For them Meds=Transport.

March 27, 2004

I have had similar circumstances happen while working for

Rural/Metro Medical Services, private as well. Rufusals were

taboo. The reason was disguised as legitimate medical reason but

most knew the real reason, THE BOTTOM LINE!!!

March 27, 2004

I have had similar circumstances happen while working for

Rural/Metro Medical Services, private as well. Rufusals were

taboo. The reason was disguised as legitimate medical reason but

most knew the real reason, THE BOTTOM LINE!!!

March 28, 2004

Maxine,

There are a couple of us here with licenses to practice law on the list.

I might as well jump in now, even though I'm exhausted. Anyways, my question

on mandatory transports is -- what happens if I don't want to let you

transport me? That violates tort law on consent as well as possibly false

imprisonment. Might even subject you to criminal charges.

As for practicing under the medical director's license, I could see MAYBE

being disallowed to practice under that doctor's license. But really, what

service operating in this gray area wants to file a complaint with TDH and be

subject to a full and complete investigation of the matter? My supposition is

that TDH will be looking a lot more closely at the service than the individual

medic if this story is correct.

-Wes Ogilvie

March 28, 2004

Steve I agree and I would like to hear more about your presentation. Email me

off list if you can.

Salvador Capuchino Jr

EMT-Paramedic

scapuchino@...

Valley EMS

www.valleyems.com

Trends

Salvador,

I do not claim to work for the perfect company or in the perfect region.

I just wanted to point out the fact that while most of us have ran across ideas

and policies with which we disagree, this one really takes the cake. Everyone

has their problems, but this one really needs to be addressed.

As far as management goes, one thing really sticks out in my mind every

time I hear someone speaking on the topic. While going through my mail I found a

quote that was posted by Louis Molino. That quote stuck in my mind and has been

a big topic of discussion in my " region " since it was posted.

Louis, I hope you don't mind, but I am going to repost that quote

because I believe it is one of the best things I have seen on this list in a

long time.

" We were dying for leadership, chafing under management "

Everyone have a great weekend,

Neil

March 28, 2004

Wes and more to Maxine, I will say this again, WE PUSH FOR TRANSPORTS. WE DO

NOT FORCE PEOPLE TO GO. I have posted a message with such a situation. THERE

IS A DIFFERENCE BETWEEN PUSHING AND FORCING. YOU COULD SAY WE ARE STUBBORN

ABOUT IT, BUT IN THE END IF YOU SAY NO, THEN OH WELL. NOW IF YOU ARE REALLY

SICK AND SHOULD GO AND CONTINUE TO REFUSE WE ASK FOR A SUP AND MAYBE EVEN PD.

THESE USUALLY WORK. AGAIN USUALLY. I AM AWARE OF THE LAW. I do respect your

advice Wes. Please contact me privately.

Salvador Capuchino Jr

EMT-Paramedic

scapuchino@...

Valley EMS

www.valleyems.com

Re: TRENDS

Maxine,

There are a couple of us here with licenses to practice law on the list.

I might as well jump in now, even though I'm exhausted. Anyways, my question

on mandatory transports is -- what happens if I don't want to let you

transport me? That violates tort law on consent as well as possibly false

imprisonment. Might even subject you to criminal charges.

As for practicing under the medical director's license, I could see MAYBE

being disallowed to practice under that doctor's license. But really, what

service operating in this gray area wants to file a complaint with TDH and be

subject to a full and complete investigation of the matter? My supposition is

that TDH will be looking a lot more closely at the service than the individual

medic if this story is correct.

-Wes Ogilvie

March 28, 2004

I have inserted comments below.

GG

In a message dated 3/28/2004 8:01:28 AM Central Standard Time,

SDralle@... writes:

I wanted to coment on this discussion as it is related to a topic I am hoping

to present at the conference. There are three big problems with patient

refusals. Depending on how they are taken it represents poor patient care,

significant liability for the medic and company and damages the financial health

of

the agency.

Now, before you set your e-mail to flame I want you to consider some basic

issues with this problem.

First, I will state clearly that I would not suppor the termination of an

employee for accepting signed refusals from a patient. I would only support

termination after there is significant evidence of that employee engaging in

repeated 'medic initiated' refusals. That is, the medic " talks the patient out

of

transport " . There have been several studies (I am on the road so I do have

them with me to cite them, but can later if needed) that indicate we are very

bad at predicting the need for ED care or hospitalization. I think this is

releated primarily to the lack of diagnostic equipment in the field and training

focused on the identification and management of emergencies rather than on the

ruling out of specific conditions. (But that is just my theory)

You are correct that there is poor correlation. However, it may result from

a number of things, not the least of which is inadequate care at the hospital.

We have experienced more than once taking a patient to a certain hospital

only to fine them almost beat us home, and two days later take them again, this

time in critical condition from a condition that was ignored or missed in the

hospital.

Aside from that, a friend who is a former Paramedic, now in 1st year

residency, tells me that he now looks at cases in a very different way from the

way

that he did as a Paramedic. Why? He has more diagnostic knowledge and tools;

he has more experience with disease progressions and outcomes, and also has the

luxury of not having to make a transport decision. Patients that are " iffy "

are simply parked in observation for a while till the labs come back and then

a decision is made. We can't sit with patients for a few hours waiting to see

how they do.

I would argue that most of us want to transport our patient and do not

intentionally talk patients out of transport but I would also argue that our

language (both spoken and implied) communicates something very different. When

you

respond to the home of an 80 year old patient complaining of headache times

four hours and slight HTN what do you ask when it comes to transport, " Do you

want to go to the hospital? " I think an arugement could clearly be made that

this question actually communicates to the patient, " You do not need to go but I

will take you. " The problem is, we would not do that with a patient that had

a knife sticking out of his chest, would we? We would say, if anything, " What

hospital do you want to go to? " More likely we would just start preperations

for transport.

Correct again. Our verbal communication and body language tells the patient

a lot. Perhaps we should learn better communications skills. But there are

pitfalls in saying too much about what we think the patient's problems are. We

run the risk of getting too far into diagnosis and practice of medicine,

which makes our medical directors very queasy indeed. I prefer to say that we

cannot rule out a serious condition in the field and that our best advice is to

seek care in the hospital. I sometimes explore alternative transportation with

family, friends, or going to a clinic, but I resist refusing to take the

patient. In my mind that's an invitation to disaster and a lawsuit.

Now, what do you do about the patient with a broken finger but no

transportation? Depends. If it's a kid and his mom with no car or no money for

gas,

then I cheerfully transport. If it's a system abuser, I'm not so eager.

I see alternative means of transport as being something that would work for

some systems; I know it has been tried, but I have the sense that it has never

worked well. Anybody have any knowledge or ideas about this?

GG

This is just a partial sample of the arguement I make in my presentation but

I did not think any of you would like to read a 5,000 word essay on the topic

in this format. I would just challenge you to think about what your body

language is and how your language changes with the age and complaint of the

patient.

As for the patient with a hang nail, warn of their risks and let them refuse.

Steve Dralle, EMT-P

San

Of course, these are just my opinions and I do not speak for my agency.

Trends

Salvador,

I do not claim to work for the perfect company or in the perfect region.

I just wanted to point out the fact that while most of us have ran across

ideas and policies with which we disagree, this one really takes the cake.

Everyone has their problems, but this one really needs to be addressed.

As far as management goes, one thing really sticks out in my mind every

time I hear someone speaking on the topic. While going through my mail I found

a quote that was posted by Louis Molino. That quote stuck in my mind and has

been a big topic of discussion in my " region " since it was posted.

Louis, I hope you don't mind, but I am going to repost that quote because

I believe it is one of the best things I have seen on this list in a long

time.

" We were dying for leadership, chafing under management "

Everyone have a great weekend,

Neil

March 28, 2004

In a message dated 3/28/2004 11:58:53 PM Central Standard Time,

hatfield@... writes:

Secondly, and I hate to play semantics, but my medical director *does

not* have the authority to 'yank my patch' he never has and never will.

He *does* have the authority to refuse to allow me to practice under his

license which would pretty much leave me unemployed.

I've seen med dir yank patches, they have pull & lots of cooperation from

TDH. If nothing else, blackballing is VERY real in the EMS community. Just be

careful.

March 28, 2004

In a message dated 3/29/2004 12:37:09 AM Central Standard Time,

Etlaesium@... writes:

That's a whole 'nother thread, and in tune with Lance's post, to become an

extension of the physician, we would be called upon to make more intense

clinical decisions. WE would have to, dare I say it? Diagnose things and not

be afraid. In essence, we would be doing the exact opposite of what you are

talking about.

This thread has gone round and round, and I posed the question, and never

received a good answer. Does every patient who dials 911 require ambulance

transport to the hospital? No. Paramedic initiated refusals are OK, they

really are, they are new, and they may be scary to those who don't have the

confidence in their skills, but they really are acceptable.

What have we always had drilled into our heads? YOU DON'T DIAGNOSE IN THE

FIELD. Treat what you see and get them to the ER for further eval. Again, even

in

the best of assessments, we still don't possess the support services (CT,

X-ray, labs) that ER's do in order to make full, concise diagnoses.

Case in point: a few years back I got called for a minor MVA. Pt was 70+ male

COAx4, with a scratch on his hand. Thought maybe he'd looked down and just

didn't see the semi stopped in front of him. He was on his way to the pharmacy

to pick up his meds. Could even tell me that the paper bag with the pill

bottles were under his driver's seat. Pt had rear-ended a semi at about 30 mph.

COMPLETELY STABLE, minor damage to his vehicle, flirted with me all the way to

the

ER. Pt was former military, so I took him to BAMC (military trauma center &

also his primary hospital) called in Code II pt report. Sweet old man, doc

treated him like a waste of time. Went back to the ER a couple of hours later &

the ER doc was hot after my ass, why? Because the pt had an aortic tear and he

thought I should've come in Code III. Know what I told him? How was I supposed

to know this? It took sophisticated diagnostic imagery for you to find it,

sorry, the CT/X-ray on my truck is broken today... Doc hated me till he PCS'ed

out, but would you have done something differently? What if you'd refused this

pt because he could've driven himself in and he coded in the WR? I am confident

in my skills, but not conceited about them. My pt lived because I gave him a

ride. That's a DAMN GOOD feeling...

Food for thought....

March 28, 2004

Gene,

I was right behind you for awhile, but I have to make a few of my own

observations.

First and foremost, I should say up front that I am a firm believer in

Paramedic initiated refusals. If you or your service employs a Paramedic

that would cause you fear by being unable to decipher what patients need

ambulance transport, and which ones don't, then either you have hired

him/her because they have 'a patch and a pulse', they need some remedial

training, or they need to be terminated.

I do agree that there are those among us who would blatantly talk a

patient out of transport to the ER, policing ourselves without a lynch

rope will often find those and again, either offer remedial training, or

eradicate them from the field.

From: wegandy1938@...

>>I would only support

>>termination after there is significant evidence of that employee

engaging >>in

>>repeated 'medic initiated' refusals.

If in fact the patient has a medical issue or condition which needs to

be evaluated by a physician *right now*, then those patients by all

means need to be transported via ambulance. If the patient does not have

an emergency medical condition, and we cannot confuse *emergency medical

condition*, with *medical condition*, then they can have alternatives

explained to them.

If the same patient is calling for the same issue, and that issue still

is not a medical emergency, then in my honest opinion, repeated medic

initiated refusals are warranted.

Alternatives may be either follow up with their personal physician at

his/her office, or, POV, or other ideas.

>>I think this is

>>releated primarily to the lack of diagnostic equipment in the field

and >>training

>>focused on the identification and management of emergencies rather

than on >>the ruling out of specific conditions.

If a medic has strong assessment skills, than the two should happen

simultaneously, one should be able to rule out certain conditions, while

at the same time identify any medical emergencies.

>>We have experienced more than once taking a patient to a certain

hospital

>>only to fine them almost beat us home, and two days later take them

again, >>this

>>time in critical condition from a condition that was ignored or missed

in >>the

>>hospital.

One could arguably state then that they apparently didn't need ambulance

transport the first time around, they did however require some

evaluation, and they did require transport the second time.

>>I would argue that most of us want to transport our patient and do not

>>intentionally talk patients out of transport but I would also argue

that >>our

>>language (both spoken and implied) communicates something very

different. >>When you respond to the home of an 80 year old patient

complaining of >>headache times four hours and slight HTN what do you

ask when it comes to >>transport, " Do you want to go to the hospital? "

I think an arugement >>could clearly be made that this question actually

communicates to the >>patient, " You do not need to go but I will take

you. " The problem is, we >>would not do that with a patient that had a

knife sticking out of his >>chest, would we? We would say, if anything,

" What hospital do you want to >>go to? "

The patient with the knife sticking out of his chest speaks for itself,

the patient with the HA and HTN, needs to be evaluated. Neither of these

patients fit a category of medic initiated refusals in my opinion.

I think the training that we receive already incorporates some

diagnostic skills, we can call it different things, but " a rose by any

other name is still a sweet smelling rose " , we do make differential

diagnosis in the field. Why are we so afraid to use the knowledge that

we have? Tell you what though, treat us like we are idiots, and we sure

get pissed off.

>>We run the risk of getting too far into diagnosis and practice of

>>medicine,

>>which makes our medical directors very queasy indeed. I prefer to say

>>that we cannot rule out a serious condition in the field and that our

best >>advice is to seek care in the hospital.

I don't have a problem telling a patient that they need to be seen, and

they need to be seen in the ER, but where does that require EMS

transport?

>>This is just a partial sample of the arguement I make in my

presentation >>but

>>I did not think any of you would like to read a 5,000 word essay on

the >>topic in this format.

Not on the list server, but I would be more than happy to read it off

line, if you have it, send it.

>>As for the patient with a hang nail, warn of their risks and let them

>>refuse.

Is this not the perfect patient for a Paramedic initiated refusal?

March 28, 2004

,

First, I can assure you that I am well aware of whose license I practice

under.

Secondly, and I hate to play semantics, but my medical director *does

not* have the authority to 'yank my patch' he never has and never will.

He *does* have the authority to refuse to allow me to practice under his

license which would pretty much leave me unemployed.

Pretty definitive difference between the two.

Your service, your company, your director, your owner, your partner.

None of them *start* the 'de certification' process, they do the same

thing your Medical Director does, they file a complaint/grievance, and

TDH does their thing. They investigate, and come to a conclusion.

Back to my original comment.

For any service to say that they will turn you in to TDH for

decertification, is an incredibly ridiculous attempt at intimidation. I

cannot count the times I have pissed off physicians for following my

protocols, of those, about 10-20% swear that they will file a compliant

with TDH, and have my patch taken away. I stand by my care, and I still

have my patch 14 years later.

Do I violate my own protocols? Nope. But I have the luxury of working

under medical directors who have a sense of good patient care.

50% patient care, 50% politics? I tend to lean a little towards 10%

patient care, 90% politics.

Respectfully,

Mike

-----Original Message-----

From: cllw602@...

It may be a line of bs when it comes to our opinion, but as I said

before,

you're practicing under THEIR license. If they've clearly stated in

their

protocols that if you push meds, you take a ride, and you don't get the

proper

documentation (a lot of medical directors want you to call them or

secondary

medical control to get " permission " ) and follow their rules, they can

and will yank

your patch. Especially in private services. They are there to make

money, no

ride, no money. It's 1/2 medicine, 1/2 politics.

March 28, 2004

Mike,

I will agree with you that not every patient requires transport to the ED,

but " paramedic-initiated refusals " are not (IMNSHO) worth the trouble. I do

agree with the concept, though. Every patient that is able to provide

informed consent for treatment must do so and transportation to the ED is a

part of the treatment plan that requires it. I am not against providing the

patient with the required information to make an informed decision, but to

say, " Ma'am, I'm not taking you to the hospital " would be a gross

disservice.

On the other hand, the expectation should not be to transport every patient

to the hospital just because they called 9-1-1. The expectation should be

to offer transport for those that require or request it. Most people that

call for EMS did not know how to handle a certain event and can be assured

that they are doing the right thing (i.e. child with a moderate fever x 1

hour and Tylenol/Motrin given by parent). We as EMS professionals should

have an instrument that allows us to formulate an adequate treatment plan

that includes transport to the ED as necessary without having to obtain a

written and informed refusal from the patient when it is not necessary. I

think that this reinforces the " call the ambulance for a ride to the

hospital " mindset.

Just some thoughts.

Mike

Re: RE: Trends

That's a whole 'nother thread, and in tune with Lance's post, to become an

extension of the physician, we would be called upon to make more intense

clinical decisions. WE would have to, dare I say it? Diagnose things and not

be afraid. In essence, we would be doing the exact opposite of what you are

talking about.

This thread has gone round and round, and I posed the question, and never

received a good answer. Does every patient who dials 911 require ambulance

transport to the hospital? No. Paramedic initiated refusals are OK, they

really are, they are new, and they may be scary to those who don't have the

confidence in their skills, but they really are acceptable.

I don't deny that the call to 911 may be because they were afraid, or hurt,

etc., being afraid, with no medical issues, does not constitute a medical

necessity for an ambulance.

Stubbed toes? 3 day old fevers? These need ambulance transport to the ER? I

think not.

Mike

Re: Trends

> >

> > Steve says good things, but the big city medics such as those San

> >

> > dewds described by one writer will eventually compose their own

> > obituary. As

> > those who pay the bills begin to realize that they're paying a bunch of

> > high-powered LazyBoys to take shortcuts and avoid using their skills,

> > they'll figure

> > out a way to get rid of them. Unions or no unions.

> >

> > GG

> >

March 28, 2004