Patient Refusal Forms of Little Value

September 28, 2006

OK. I'll give you another example.

I am headed to the grocery store recently and see medics off loading someone

there (i.e. patient not being transported.) I nose around and found out the

patient is 'refusing " transport. The original complaint is essentially

aletered mental status. When the wife arrives the entire group of them

decide it must be due to a new medicine that the patient is on and so he can

go home with the wife.

Is that appropriate? They may be right, but that seems like an ER

evaluation decision (physician eval) and very dangerous to make in the

parking lot by those involved.

I'll give you another one. My friend gets stung by a bee and panics and

calls 911 (allergic reaction.) EMS arrives and gives 50mg IM Benadryl.

THey decide its not serious enough to transport. They courteously follow

her home. Later she is found asleep on the couch which is now burned

because she fell asleep smoking.

She thought it was great care and was happy to be treated and receive no

bill. I thought it was irresponsible.

I have seen dialysis patients not transported for belly pain (peritoneal

dialysis.) I have been flabbergasted so many times I can't remember.

All of the above cases are hypothetical and should not be deemed admissible

as fact in a court of law if found on the internet =)

Kirk D. Mahon, MD, ABEM

6106 Keller Springs Rd

Dallas, TX 75248

September 29, 2006

work for Acadian Ambulance in Orange, TX, Our refusal

system is we try not to get them if we have to get one

the paramedic must take the first one,then the Jr.

medic can take any others on scene. We also have a

policy of " You call, We haul " as my wife posted in

another thread. We ask which hospital do they want to

go to not do you want to go to the hospital. i find

that I've been getting less refusals now, in fact the

only refusals I've gotten recently where from MVA

" fender benders "

H. Ben Ballard EMT-B, HSE

Three Can Keep A Secret If Two Are Dead!!!

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src= " http://x.myspace.com/images/Promo/myspace_4.jpg " border= " 0 " > <img

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border= " 0 " > Check

me out!</a>

__________________________________________________

September 29, 2006

Yea, not to mention the patient's day.

LMc

wegandy1938@... wrote:

I can't remember where it was done, probably Mr. Bledson knows, but

there has

been a study done that attempted to measure the abilities of pre-hospital

caregivers to determine which patients would be admitted to the hospital. The

results were abysmal.

Bledsoe, I think it was, or another astute physician, once told me that the

scariest thing about being an ER doctor is making the decision who to admit and

who to discharge. And this is from someone who has the education and

training, all the toys, bells, and whistles, to diagnose.

I like Henry's approach. Let's take that " anxious " patient. I want to

know WHY the patient is anxious. Lots of times patients are anxious because

they think they're about to die, and lots of the time they're right. It's

extremely embarrassing to have left a patient, thinking that all they need is to

take an aspirin and call their family doctor in the morning, only to be called

back one hour later for a code.

Ruins one's day.

Gene G.

September 29, 2006

Good patient advocacy and good documentation are the best lawyer repellants.

When writing a " critical " refusal, you SHOULD write more than you do in the

actual report. A repeat:

Every refusal form must show through independent facts, not conclusions:

1. The patient had the present mental capacity to understand and appreciate

their medical condition, the possible consequences of refusal, and to form a

rational judgment based upon facts.

2. Evidence that the patient was given specific and adequate information

about his condition, as then known or reasonably discoverable by the medics, so

as to enable him to make an informed decision about his health care.

3. Evidence that the patient received and understood the information given,

documented with facts, not conclusions. " Understood " is a conclusionary

term. It takes factual demonstration based upon the patient's quoted

statements, to show this.

4. The patient's documented statement to the effect that he is making the

decision not to be treated and transported based upon the documented facts that

he has demonstrated that he understood.

5. Signatures of patient and witnesses with identifying data.

Check your refusal form. Does it meet this standard?

Gene G.

September 29, 2006

My $0.02 for those interested:

I've always worked under the assumption, " if you feel it necessary to give

medication, then transport them. " The only times this hasn't always been the

case has been known diabetics who have received D50, wake up and refuse

transport, or (in one system in Missouri) known asthmatics who have one

treatment (of their usual meds) using our equipment and then refuse. I ALWAYS

call med control with these and ensure there is family there that get the speel

and sign the refusal as well.

If I do an EKG on scene, I also call med control. (And that's usually because

I think they need to go, but they refuse anyway.)

I worked the hard core ghetto for a while, and it's a bit different. MANY,

MANY, MANY a time we were called for mere taxi service. And I mean just

that-- " I wanna go see my social worker, she's near the hospital, so you hafta

take me cuz I called 911s! " If they wanted to go, away we went. When it came

to refusals, if it was a third party call, such as in an MVA, if no one was

injured and refused transport, we did not do refusals on them, we did a " cleared

from scene, third party call. " Many a time, we were called just to " check them

out. " I spent many a day doing blood pressure checks, blood sugar checks, " does

this look like it needs stitches? " checks, " does this look infected? " checks,

" can you cut this hangnail for me? " checks, " can I get some drugs? " checks...And

the list goes on. And we always did the same. We took vitals, blood sugar,

cleaned and dressed any cuts, called cops if necessary, etc. I repeated

something along these lines a lot: " I have done all

the assessment that I am able to, and your vitals/blood sugar/etc. are

average/high/low by average standards and by our equipment. However, this may

not be normal for you. I am not a doctor, nor do I have all of the tests and

equipment available that the hospital has. I am more than happy to transport you

to the hospital of your choice, but I also cannot force you to go. " Maybe this

is bad, I dunno.

I'm not thrilled with refusals, either; I write more on refusals than

transports (for the most part).

Maybe we should all get the cameras that police have, mic up, and record every

refusal for posterity and lawsuits.

Blake-

TX LP, NREMT-P, TX EMSI

AIM: SinaptiK

" Medicine, the only profession that labors

incessantly to destroy the reason for its

existence. " Bryce

Facebook me!

---------------------------------

Stay in the know. Pulse on the new Yahoo.com. Check it out.

October 1, 2006

A well thought out form can be an aid in getting the right information down,

no question about it. However, it all cames back to the person filling out

the form.

If the right questions are not asked, and the right assessments done, no

piece of paper can help. It depends upon education, experience, and judgment.

GG

>

> So what is the problem actually?

>

> Is it the forms?

>

> Or is it the personnel doing the refusals?

>

> Or is it a combination of both?

>

> Perhaps better training of what a patient refusal form is for and what it is

> not for would be a good starting point?

>

> Perhaps then a refusal form that would meet the requirements and not leave

> such a gap for lawsuits to occur?

>

> Or do we just leave it at transport everyone that wants to ride in the

> woo-woos'?

>

> Or is it that the patients rights are flung out the door and we make then

> ride in our bus regardless?

>

> I am pretty sure of the questions. Not so sure about the answers.

>

> wegandy1938@wegandy wrote:

> The main reason I don't refuse patients who I'm tempted to think don't have

> anything serious wrong with them is NOT what I know, but what I know that I

> DON'T know.

>

> For example, here are some of the causes of abdominal pain:

>

> parietal peritoneal inflammation due to infection (appendix, PID)

> parietal peritoneal inflammation due to chemical irritation (perforated

> gastric or peptic ulcer; pancreatitis, Mittelschmerz, ruptured ectopic

> pregnancy)

> inflammation of bowel wall

> Crohn's disease,

> ulcerative colitis,

> microscopic colitis

> diverticulitis

> gastroenteritis

> lactose intolerance

> celiac sprue

> sarcoidosis

> vasculitis

> mechanical obstruction of hollow viscera

> gallstones

> vascular disturbances

> embolism

> thrombosis

> vascular rupture

> torsional occlusion (volvulus)

> sickle cell anemia

> renal vein entrapment

> superior mesenteric artery syndrome (nutcracker syndrome)

> mesenteric traction

> muscle trauma

> muscular infection

> distention of visceral surfaces such as hepatic or renal capsule

> referred pain from the thorax (MI, pneumonia), spine, genitals (testicular

> torsion)

> metabolic disturbance (lead poisoning, black widow spider bite, uremia, DKA,

> porphyria, C1-esterase inhibitor deficiency, adrenal insufficiency)

> tabes dorsalis

> herpes zoster

> Lyme disease

> Irritable Bowel Syndrome

> torsion of the ovary, endometriosis

> diarrhea

> meningitis

> cholecystitis

> pyelonephritis

> hepatitis

> mesenteric adenitis

> subdiaphragmatic abscess

> cancer of the ovary, bowel, stomach, liver, kidney, etc

> ascites

>

> And there are surely others

>

> Any medic who feels comfortable telling someone with vague abdominal pain

> that it's just an upset stomach is playing with fire, and will soon see the

> judge

> and jury. And that's the kindest thing I can say about such a person.

>

> If I were a board certified general surgeon or gastroenterologist in the

> ambulance, I still wouldn't street such a patient. Yet paramedics do it

> every

> day.

>

> It boggles the mind.

>

> Gene G.

>

October 1, 2006

So surely for the person who called for the taxi service with the below

statement was turned in for false report of an emergency????

Blake- wrote:

My $0.02 for those interested:

I've always worked under the assumption, " if you feel it necessary to give

medication, then transport them. " The only times this hasn't always been the

case has been known diabetics who have received D50, wake up and refuse

transport, or (in one system in Missouri) known asthmatics who have one

treatment (of their usual meds) using our equipment and then refuse. I ALWAYS

call med control with these and ensure there is family there that get the speel

and sign the refusal as well.

If I do an EKG on scene, I also call med control. (And that's usually because I

think they need to go, but they refuse anyway.)

I worked the hard core ghetto for a while, and it's a bit different. MANY, MANY,

MANY a time we were called for mere taxi service. And I mean just that-- " I wanna

go see my social worker, she's near the hospital, so you hafta take me cuz I

called 911s! " If they wanted to go, away

Blake-

TX LP, NREMT-P, TX EMSI

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October 1, 2006

So what is the problem actually?

Is it the forms?

Or is it the personnel doing the refusals?

Or is it a combination of both?

Perhaps better training of what a patient refusal form is for and what it is

not for would be a good starting point?

Perhaps then a refusal form that would meet the requirements and not leave

such a gap for lawsuits to occur?

Or do we just leave it at transport everyone that wants to ride in the

woo-woos'?

Or is it that the patients rights are flung out the door and we make then ride

in our bus regardless?

I am pretty sure of the questions. Not so sure about the answers.

wegandy1938@... wrote:

The main reason I don't refuse patients who I'm tempted to think don't

have

anything serious wrong with them is NOT what I know, but what I know that I

DON'T know.

For example, here are some of the causes of abdominal pain:

parietal peritoneal inflammation due to infection (appendix, PID)

parietal peritoneal inflammation due to chemical irritation (perforated

gastric or peptic ulcer; pancreatitis, Mittelschmerz, ruptured ectopic

pregnancy)

inflammation of bowel wall

Crohn's disease,

ulcerative colitis,

microscopic colitis

diverticulitis

gastroenteritis

lactose intolerance

celiac sprue

sarcoidosis

vasculitis

mechanical obstruction of hollow viscera

gallstones

vascular disturbances

embolism

thrombosis

vascular rupture

torsional occlusion (volvulus)

sickle cell anemia

renal vein entrapment

superior mesenteric artery syndrome (nutcracker syndrome)

mesenteric traction

muscle trauma

muscular infection

distention of visceral surfaces such as hepatic or renal capsule

referred pain from the thorax (MI, pneumonia), spine, genitals (testicular

torsion)

metabolic disturbance (lead poisoning, black widow spider bite, uremia, DKA,

porphyria, C1-esterase inhibitor deficiency, adrenal insufficiency)

tabes dorsalis

herpes zoster

Lyme disease

Irritable Bowel Syndrome

torsion of the ovary, endometriosis

diarrhea

meningitis

cholecystitis

pyelonephritis

hepatitis

mesenteric adenitis

subdiaphragmatic abscess

cancer of the ovary, bowel, stomach, liver, kidney, etc

ascites

And there are surely others

Any medic who feels comfortable telling someone with vague abdominal pain

that it's just an upset stomach is playing with fire, and will soon see the

judge

and jury. And that's the kindest thing I can say about such a person.

If I were a board certified general surgeon or gastroenterologist in the

ambulance, I still wouldn't street such a patient. Yet paramedics do it every

day.

It boggles the mind.

Gene G.

October 1, 2006

Why is a person who doesn't have transportation not afforded this by EMS?

Why would a supervisor not see the need and transport in his supervisor

vehicle?

Where is the emergency, with us, or with our patients?

Transport is still a transport, albeit BLS right?

wegandy1938@... wrote:

Dear Humble,

You're right if the world were perfect. And you're probably right that SOME

medics can make those distinctions.

I have no problem with discussing alternatives with the patient with an

isolated minor finger laceration, a stubbed toe, and so forth, but in all cases

it

is preferable for the patient to make the decision for treat and transport vs.

no treat and transport.

The abusers are a problem all their own. What they really need is social

services to help them with the underlying problems that cause them to abuse.

But all in all, if a patient really wants to go, I'm going to take them. I

don't ever want to have it come back on me that I refused someone who actually

needed treatment.

I remember one night with a large city FD EMS where we made three calls to

the same place for a 3 year old child with an earache. Each time the mother

was told that this wasn't an emergency and that she should drive to the ER

with the child herself. She pleaded that she did not have transportation, et

cetera. I could hardly keep my mouth shut, but since I was a guest, I did.

However, on the third call, one of the medics made the astute observation that

we might as well go ahead and transport because we were going to get called

all night if we didn't. So on the third time we transported.

Of course, if that service had ANY sort of effective supervision at that

time, that wouldn't have happened. The kid was sick. I'm told that things have

changed. I certainly hope so.

GG

>

> There are actually a number of studies out there that talk about Paramedic

> initiated refusals.

>

> In some instances it is a liability looking for a place to happen, however,

> there are instances that Paramedic initiated refusals are appropriate. Now

> before we get a rope and look for a tall tree..let me explain. In instances

> where a definitive cause of a sign or symptom cannot be found, then the

> patient should in fact be transported, or be encouraged to be transported,

> syncope in the elderly, as explained by Mike , is generally caused by a

> cardiac event of some kind, and should never be ignored or played down,

> treated with a high index of suspicion and cared for accordingly. Abdominal

> pain is another catch all for transport, etc. etc.

>

> There area small number of abusers of the system. Those that require a

> ride, and nothing more. Do they need a ride? Yep. Do they need a ride in an

> ambulance? Nope. Can we arrange for alternative transportation? That's the

> question. Then it comes down to, which patients qualify for alternative

> transport.

>

> I do believe that with the right training, the right oversight and good QI,

> that there are a number of patients that can be refused transport.

>

> Are there medics who are not astute enough to learn it? Are there some that

> will get refusals because they are too lazy to transport? Yes on both

> counts, and they need to find another career field, we cannot slow this

> field down for the slowest person, we need to continue to move forward and

> thin the herd as necessary.

>

> Just my humble opinion...being the humble person that I am.:-)

>

> Mike

>

> Hatfield FF/EMT-P

>

> www.canyonlakefire- www.ca

>

> " Ubi concordia, ibi victoria "

>

> Re: Patient Refusal Forms of Little Value

>

> I can't remember where it was done, probably Mr. Bledson knows, but there

> has

> been a study done that attempted to measure the abilities of pre-hospital

> caregivers to determine which patients would be admitted to the hospital.

> The

> results were abysmal.

>

> Bledsoe, I think it was, or another astute physician, once told me that the

> scariest thing about being an ER doctor is making the decision who to admit

> and

> who to discharge. And this is from someone who has the education and

> training, all the toys, bells, and whistles, to diagnose.

>

> I like Henry's approach. Let's take that " anxious " patient. I want to

> know WHY the patient is anxious. Lots of times patients are anxious because

> they think they're about to die, and lots of the time they're right. It's

> extremely embarrassing to have left a patient, thinking that all they need

> is to

> take an aspirin and call their family doctor in the morning, only to be

> called

> back one hour later for a code.

>

> Ruins one's day.

>

> Gene G.

>

October 2, 2006

The 911 call for transportation to the social workers office (or add

your non medical reason for transportation) next to the hospital is much

more common in many cities that you would believe. As far as reporting

someone for a false report of an emergency - anything short of a federal

funded FBI task force on 911 abuse with federal agents knocking down

doors to make a late night arrest isn't going to make much of a

difference. Tongue firmly in cheek!!! The cold truth is that most

communities other than rural counties are not going to bother

prosecuting a 911 abuse case. There isn't the time or the money to

really bother with it.

AJL

________________________________

From: texasems-l [mailto:texasems-l ] On

Behalf Of Danny

Sent: Sunday, October 01, 2006 7:35 PM

To: texasems-l

Subject: Re: Re: Patient Refusal Forms of Little Value

So surely for the person who called for the taxi service with the below

statement was turned in for false report of an emergency????

Blake- <paramedicbbt@...

<mailto:paramedicbbt%40yahoo.com> > wrote:

My $0.02 for those interested:

I've always worked under the assumption, " if you feel it necessary to

give medication, then transport them. " The only times this hasn't always

been the case has been known diabetics who have received D50, wake up

and refuse transport, or (in one system in Missouri) known asthmatics

who have one treatment (of their usual meds) using our equipment and

then refuse. I ALWAYS call med control with these and ensure there is

family there that get the speel and sign the refusal as well.

If I do an EKG on scene, I also call med control. (And that's usually

because I think they need to go, but they refuse anyway.)

I worked the hard core ghetto for a while, and it's a bit different.

MANY, MANY, MANY a time we were called for mere taxi service. And I mean

just that-- " I wanna go see my social worker, she's near the hospital, so

you hafta take me cuz I called 911s! " If they wanted to go, away

October 2, 2006

I have been working in a system that has been doing paramedic initiated

no transports for 7 years now. Simple trauma only, no medical

complaints and the elderly and pediatrics are excluded. A patient with

any other intervention besides an assessment and vital signs are also

excluded. We still consider it to be a pilot program - longest pilot

program that I have ever encountered - but it has moved over the years

with baby steps. So far no lawsuits or adverse patient outcomes. It's

not something you can do in a vacuum nor can you just go out and

instruct people to say no we aren't going to transport you. We were

prepared to invest in time (seven years and we are still tweaking it)

training, education, oversight and yes learning from a few mistakes.

Is adding more ambulances to run more calls the answer to rising call

volumes? Although finances were never a consideration for us what else

can be done (other than adding more ambulances) especially when you are

confronted with ever decreasing reimbursements?

AJL

________________________________

From: texasems-l [mailto:texasems-l ] On

Behalf Of Hatfield

Sent: Thursday, September 28, 2006 8:57 PM

To: texasems-l

Subject: RE: Patient Refusal Forms of Little Value

There are actually a number of studies out there that talk about

Paramedic

initiated refusals.

In some instances it is a liability looking for a place to happen,

however,

there are instances that Paramedic initiated refusals are appropriate.

Now

before we get a rope and look for a tall tree..let me explain. In

instances

where a definitive cause of a sign or symptom cannot be found, then the

patient should in fact be transported, or be encouraged to be

transported,

syncope in the elderly, as explained by Mike , is generally caused

by a

cardiac event of some kind, and should never be ignored or played down,

treated with a high index of suspicion and cared for accordingly.

Abdominal

pain is another catch all for transport, etc. etc.

There area small number of abusers of the system. Those that require a

ride, and nothing more. Do they need a ride? Yep. Do they need a ride in

an

ambulance? Nope. Can we arrange for alternative transportation? That's

the

question. Then it comes down to, which patients qualify for alternative

transport.

I do believe that with the right training, the right oversight and good

QI,

that there are a number of patients that can be refused transport.

Are there medics who are not astute enough to learn it? Are there some

that

will get refusals because they are too lazy to transport? Yes on both

counts, and they need to find another career field, we cannot slow this

field down for the slowest person, we need to continue to move forward

and

thin the herd as necessary.

Just my humble opinion...being the humble person that I am.:-)

Mike

Hatfield FF/EMT-P

www.canyonlakefire-ems.org

" Ubi concordia, ibi victoria "

Re: Patient Refusal Forms of Little Value

I can't remember where it was done, probably Mr. Bledson knows, but

there

has

been a study done that attempted to measure the abilities of

pre-hospital

caregivers to determine which patients would be admitted to the

hospital.

The

results were abysmal.

Bledsoe, I think it was, or another astute physician, once told me that

the

scariest thing about being an ER doctor is making the decision who to

admit

and

who to discharge. And this is from someone who has the education and

training, all the toys, bells, and whistles, to diagnose.

I like Henry's approach. Let's take that " anxious " patient. I want to

know WHY the patient is anxious. Lots of times patients are anxious

because

they think they're about to die, and lots of the time they're right.

It's

extremely embarrassing to have left a patient, thinking that all they

need

is to

take an aspirin and call their family doctor in the morning, only to be

called

back one hour later for a code.

Ruins one's day.

Gene G.

October 2, 2006

I appreciate what you're saying. I think you've got the right approach.

There are alternatives to transporting everyone by ambulance. For various

reasons, those have not been tried or have been tried and deemed not to work.

I would be in favor of the service providing non-ambulance transportation in

a service owned vehicle, with a trained driver, that do not really need

immediate care but who should be seen before their regular physician could see

them.

Some of those could be triaged to a Doc-In-The-Box perhaps. These are

people who might need a dressing change and don't have home health care, who

have

minor sprains, or a dislocated finger, or a stubbed toe, or a finger mashed

in the door, et cetera. Although those might need pain relief, in which case

they'd get transported by ambulance.

The regs don't allow this sort of transport, but maybe it's something that

should be looked at in a thoughtful way to see whether or not some money and

manpower could be saved by using alternative transportation provided by the EMS

service.

That said, service initiated refusals are still a river full of piranhas.

Gene G.

>

> I have been working in a system that has been doing paramedic initiated

> no transports for 7 years now. Simple trauma only, no medical

> complaints and the elderly and pediatrics are excluded. A patient with

> any other intervention besides an assessment and vital signs are also

> excluded. We still consider it to be a pilot program - longest pilot

> program that I have ever encountered - but it has moved over the years

> with baby steps. So far no lawsuits or adverse patient outcomes. It's

> not something you can do in a vacuum nor can you just go out and

> instruct people to say no we aren't going to transport you. We were

> prepared to invest in time (seven years and we are still tweaking it)

> training, education, oversight and yes learning from a few mistakes.

>

> Is adding more ambulances to run more calls the answer to rising call

> volumes? Although finances were never a consideration for us what else

> can be done (other than adding more ambulances) especially when you are

> confronted with ever decreasing reimbursements?

>

> AJL

>

> ____________ ________ ________ _

>

> From: texasems-l@yahoogrotexasem [mailto:texasems-l@yahoogrotexasem] On

> Behalf Of Hatfield

> Sent: Thursday, September 28, 2006 8:57 PM

> To: texasems-l@yahoogrotexasem

> Subject: RE: Patient Refusal Forms of Little Value

>

> There are actually a number of studies out there that talk about

> Paramedic

> initiated refusals.

>

> In some instances it is a liability looking for a place to happen,

> however,

> there are instances that Paramedic initiated refusals are appropriate.

> Now

> before we get a rope and look for a tall tree..let me explain. In

> instances

> where a definitive cause of a sign or symptom cannot be found, then the

> patient should in fact be transported, or be encouraged to be

> transported,

> syncope in the elderly, as explained by Mike , is generally caused

> by a

> cardiac event of some kind, and should never be ignored or played down,

> treated with a high index of suspicion and cared for accordingly.

> Abdominal

> pain is another catch all for transport, etc. etc.

>

> There area small number of abusers of the system. Those that require a

> ride, and nothing more. Do they need a ride? Yep. Do they need a ride in

> an

> ambulance? Nope. Can we arrange for alternative transportation? That's

> the

> question. Then it comes down to, which patients qualify for alternative

> transport.

>

> I do believe that with the right training, the right oversight and good

> QI,

> that there are a number of patients that can be refused transport.

>

> Are there medics who are not astute enough to learn it? Are there some

> that

> will get refusals because they are too lazy to transport? Yes on both

> counts, and they need to find another career field, we cannot slow this

> field down for the slowest person, we need to continue to move forward

> and

> thin the herd as necessary.

>

> Just my humble opinion...being the humble person that I am.:-)

>

> Mike

>

> Hatfield FF/EMT-P

>

> www.canyonlakefire- www.ca

>

> " Ubi concordia, ibi victoria "

>

> Re: Patient Refusal Forms of Little Value

>

> I can't remember where it was done, probably Mr. Bledson knows, but

> there

> has

> been a study done that attempted to measure the abilities of

> pre-hospital

> caregivers to determine which patients would be admitted to the

> hospital.

> The

> results were abysmal.

>

> Bledsoe, I think it was, or another astute physician, once told me that

> the

> scariest thing about being an ER doctor is making the decision who to

> admit

> and

> who to discharge. And this is from someone who has the education and

> training, all the toys, bells, and whistles, to diagnose.

>

> I like Henry's approach. Let's take that " anxious " patient. I want to

> know WHY the patient is anxious. Lots of times patients are anxious

> because

> they think they're about to die, and lots of the time they're right.

> It's

> extremely embarrassing to have left a patient, thinking that all they

> need

> is to

> take an aspirin and call their family doctor in the morning, only to be

> called

> back one hour later for a code.

>

> Ruins one's day.

>

> Gene G.

>

October 2, 2006

I think you're right on both points. The more I think about it, I doubt

that alternative transport is prohibited. I'll have to seek the advice of one

of the DSHS people before I'm sure.

I think we should be allowed to transport to clinics and other non-hospital

destinations where appropriate. The problem is that there are some medics who

don't have sense enough to know which ones to take where. And that's sad.

On the subject of reimbursement, who the heck knows? I've never understood

reimbursement very well except that you never get paid what your services are

worth.

Gene

>

> Gene,

>

> A couple of questions. The regs don't allow these type of transports? I am

> not sure the type of transport you describe is regulated... A couple of

> questions. The regs don't allow these type of transports? I am not sure the

type of

> transport you describe is reg

>

> The other question I have is why don't we transport, even as ambulances,

> transport to minor emergency clinics...community health clinics, etc?

>

> Now, I know payment for these services probably isn't available... Now, I

> know payment for these services probably isn't available...and that

> certainly would prevent many from doing this...but since many insurances are

> encouraging their customers to NOT call 911 and to call an 800 number so that

a

> more appropriate " preferred provider " can be contacted that will respond from

20

> minutes away while the 911 ambulance 4 minutes away sits in the barn....so w

> Now, I know payment for these services probably isn't available...and

> that certainly would prevent many from do

>

> Thoughts?

>

> Dudley

>

> Re: Patient Refusal Forms of Little Value

> >

> > I can't remember where it was done, probably Mr. Bledson knows, but

> > there

> > has

> > been a study done that attempted to measure the abilities of

> > pre-hospital

> > caregivers to determine which patients would be admitted to the

> > hospital.

> > The

> > results were abysmal.

> >

> > Bledsoe, I think it was, or another astute physician, once told me that

> > the

> > scariest thing about being an ER doctor is making the decision who to

> > admit

> > and

> > who to discharge. And this is from someone who has the education and

> > training, all the toys, bells, and whistles, to diagnose.

> >

> > I like Henry's approach. Let's take that " anxious " patient. I want to

> > know WHY the patient is anxious. Lots of times patients are anxious

> > because

> > they think they're about to die, and lots of the time they're right.

> > It's

> > extremely embarrassing to have left a patient, thinking that all they

> > need

> > is to

> > take an aspirin and call their family doctor in the morning, only to be

> > called

> > back one hour later for a code.

> >

> > Ruins one's day.

> >

> > Gene G.

> >

October 2, 2006

Gene,

A couple of questions. The regs don't allow these type of transports? I am not

sure the type of transport you describe is regulated...all that is regulated is

ambulance transport from what I have read...and that is (now anyway) someone

being moved by stretcher....

The other question I have is why don't we transport, even as ambulances,

transport to minor emergency clinics...community health clinics, etc?

Now, I know payment for these services probably isn't available...and that

certainly would prevent many from doing this...but since many insurances are

encouraging their customers to NOT call 911 and to call an 800 number so that a

more appropriate " preferred provider " can be contacted that will respond from 20

minutes away while the 911 ambulance 4 minutes away sits in the barn....so why

wouldn't they be willing to pay for transport to a minor emergency...seems they

could pay for these transport since the cost savings will be in not having to

pay the hospital charges....

Thoughts?

Dudley

Re: Patient Refusal Forms of Little Value

>

> I can't remember where it was done, probably Mr. Bledson knows, but

> there

> has

> been a study done that attempted to measure the abilities of

> pre-hospital

> caregivers to determine which patients would be admitted to the

> hospital.

> The

> results were abysmal.

>

> Bledsoe, I think it was, or another astute physician, once told me that

> the

> scariest thing about being an ER doctor is making the decision who to

> admit

> and

> who to discharge. And this is from someone who has the education and

> training, all the toys, bells, and whistles, to diagnose.

>

> I like Henry's approach. Let's take that " anxious " patient. I want to

> know WHY the patient is anxious. Lots of times patients are anxious

> because

> they think they're about to die, and lots of the time they're right.

> It's

> extremely embarrassing to have left a patient, thinking that all they

> need

> is to

> take an aspirin and call their family doctor in the morning, only to be

> called

> back one hour later for a code.

>

> Ruins one's day.

>

> Gene G.

>

October 3, 2006

So surely for the person who called for the taxi service with the below

statement was turned in for false report of an emergency??? ?

We filled in a report and all that jazz, but I highly doubt anything came of

it. This was in the hardcore ghetto; the woman (and I use the term loosely) had

no permanent address, had a history of all sorts of criminal and drug-related

charges, etc. etc. If we actually prosecuted everyone that pulled that, there

would be no cops left to run the county. (They usually have enough presence of

mind to make up some excuse like " I have a headache " when we started questioning

them after the " oh, my ride's here; I'll meet ya at Sha-naynay's crib in a few "

statement when we walked in.) I thought maybe the idea that the service won't

get paid might make a difference, but nah.

Blake-

TX LP, NREMT-P, TX EMSI

AIM: SinaptiK

" Medicine, the only profession that labors

incessantly to destroy the reason for its

existence. " Bryce

Facebook me!

---------------------------------

Get your email and more, right on the new Yahoo.com

October 3, 2006

The problem with 'taxi patients' is that many studies have shown that

paramedics are poor at determining who needs treatment and transportation, and

who

will actually be admitted to the hospital.

One of the reasons is that we don't have access to radiology and labs, but,

sadly, another one is that we are not trained well in general medicine.

So about the time you think that Miss EMS Abuser has called you one too many

times, and you're mad and tempted to " no-ride " her, that's the time that she

actually has PID and dies from septic shock. And low and behold, out of the

woodwork come relatives who see her death as winning the lottery.

I few days ago I posted a list of differential diagnoses for abdominal pain.

We can find similar lists for practically every pain that can be described.

I am not skilled in lie detection, although I have my ideas, but if

challenged in Court, I would never be able to explain why I denied a patient

treatment

and transport for a " headache. " I have had lots of experience in talking

with people who lie, and I have been fooled. Not often, but enough times that

I

never rely upon my gut reaction when making a treatment/transport decision.

Even polygraphs are not reliable enough to be admissible in court.

I see us using alternative means of transport for those patients who are

looking for a taxi ride. That would take the pressure from overworked EMS

crews.

But if that is not available, then we must do the right thing FOR THE

PATIENT, NOT FOR US, OR THE SERVICE.

Most of the abusers have some medical problems and lots of social problems.

Drug addiction is a medical problem, and lack of transportation is a social

problem.

The bad thing about it all is that we do not have a pervasive public health

plan for dealing with these patients.

The public health service people don't talk to EMS, and they should. But

communication is two way. We don't reach out to the public health service

people and say, " HEY, we've got some big problems caused by these prostitutes

and

drug abusers who use our services for other reasons than for emergency medical

care. We need to get together and work out some plans. " Unfortunately,

that almost never happens.

I would like to hear from anybody who has a plan in place to deal with those

patients through social services and public health resources.

Gene G.

>

> So surely for the person who called for the taxi service with the below

> statement was turned in for false report of an emergency??? ?

>

> We filled in a report and all that jazz, but I highly doubt anything came of

> it. This was in the hardcore ghetto; the woman (and I use the term loosely)

> had no permanent address, had a history of all sorts of criminal and

> drug-related charges, etc. etc. If we actually prosecuted everyone that pulled

that,

> there would be no cops left to run the county. (They usually have enough

> presence of mind to make up some excuse like " I have a headache " when we

started

> questioning them after the " oh, my ride's here; I'll meet ya at Sha-naynay's

> crib in a few " statement when we walked in.) I thought maybe the idea that

> the service won't get paid might make a difference, but nah.

>

> Blake-

> TX LP, NREMT-P, TX EMSI

> AIM: SinaptiK

> " Medicine, the only profession that labors

> incessantly to destroy the reason for its

> existence. " Bryce

>

> Facebook me!

>

> ------------ -------- -------- --

> Get your email and more, right on the new Yahoo.com

>

October 4, 2006

On a related note, last weekend local news reports Dallas Fire Rescue

responded to a man with severe abdominal pain and in front of multiple

witnesses told the patient to take some antacid and then they packed

their stuff and left. One witness told the news reporter that the

medics told her on the way out not to call them back. The man was found

dead in his apartment the next morning reportedly from a bleeding ulcer.

You can say whatever you want about it but I personally think that you

are better off just giving them a 10 minute ride to the ER than spending

20 mins talking them out of going and I fully believe that as a public

provider (or private sole provider of 911) you don't have the right to

refuse anyone services, " you call we haul " . If you have a system (not

specifically referring to Dallas Fire Rescue) that has no accountability

(or a weak one) process and allow your medics to refuse transport you

are always going to have these situations come up.

Just my 2 cents

Lee

Re: Re: Patient Refusal Forms of Little Value

The problem with 'taxi patients' is that many studies have shown that

paramedics are poor at determining who needs treatment and

transportation, and who

will actually be admitted to the hospital.

One of the reasons is that we don't have access to radiology and labs,

but,

sadly, another one is that we are not trained well in general medicine.

So about the time you think that Miss EMS Abuser has called you one too

many

times, and you're mad and tempted to " no-ride " her, that's the time that

she

actually has PID and dies from septic shock. And low and behold, out of

the

woodwork come relatives who see her death as winning the lottery.

I few days ago I posted a list of differential diagnoses for abdominal

pain.

We can find similar lists for practically every pain that can be

described.

I am not skilled in lie detection, although I have my ideas, but if

challenged in Court, I would never be able to explain why I denied a

patient treatment

and transport for a " headache. " I have had lots of experience in talking

with people who lie, and I have been fooled. Not often, but enough times

that I

never rely upon my gut reaction when making a treatment/transport

decision.

Even polygraphs are not reliable enough to be admissible in court.

I see us using alternative means of transport for those patients who are

looking for a taxi ride. That would take the pressure from overworked

EMS crews.

But if that is not available, then we must do the right thing FOR THE

PATIENT, NOT FOR US, OR THE SERVICE.

Most of the abusers have some medical problems and lots of social

problems.

Drug addiction is a medical problem, and lack of transportation is a

social

problem.

The bad thing about it all is that we do not have a pervasive public

health

plan for dealing with these patients.

The public health service people don't talk to EMS, and they should. But

communication is two way. We don't reach out to the public health

service

people and say, " HEY, we've got some big problems caused by these

prostitutes and

drug abusers who use our services for other reasons than for emergency

medical

care. We need to get together and work out some plans. " Unfortunately,

that almost never happens.

I would like to hear from anybody who has a plan in place to deal with

those

patients through social services and public health resources.

Gene G.

In a message dated 10/3/06 6:41:08 PM, paramedicbbt@...

<mailto:paramedicbbt%40yahoo.com> writes:

>

> So surely for the person who called for the taxi service with the

below

> statement was turned in for false report of an emergency??? ?

>

> We filled in a report and all that jazz, but I highly doubt anything

came of

> it. This was in the hardcore ghetto; the woman (and I use the term

loosely)

> had no permanent address, had a history of all sorts of criminal and

> drug-related charges, etc. etc. If we actually prosecuted everyone

that pulled that,

> there would be no cops left to run the county. (They usually have

enough

> presence of mind to make up some excuse like " I have a headache " when

we started

> questioning them after the " oh, my ride's here; I'll meet ya at

Sha-naynay's

> crib in a few " statement when we walked in.) I thought maybe the idea

that

> the service won't get paid might make a difference, but nah.

>

> Blake-

> TX LP, NREMT-P, TX EMSI

> AIM: SinaptiK

> " Medicine, the only profession that labors

> incessantly to destroy the reason for its

> existence. " Bryce

>

> Facebook me!

>

> ------------ -------- -------- --

> Get your email and more, right on the new Yahoo.com

>

October 4, 2006

Gene,

One of the many thousands of reasons that EMS should be in the Public Health

Department is exactly as you mentioned. Beaumont EMS is in the health

department and we have a referral form that can go to many of the social

services, CPS, APS, Public Health, Environmental Health, Animal Control,

Transportation Services, and Public Health Nursing. Each day, as members of our

team encounter problems that can be referred to these services, this form is

filled out, with a copy of the run sheet, history of calls to our ambulance,

etc. It is a wonderful tool that can cut responses for many reasons.

Beaumont EMS takes the time on all calls to see if the elderly have their meds

in order, not taking 2 of the same meds each day, have food in their

refrigerator, running water, toilets operating, etc. We also make sure that

they have someone coming by their home and checking on them regularly, are they

under Home Health Care and if not and they need to be, we initiate that process.

Mental illnessess are referred to the proper channels, unclean environments due

to 28 dogs and cats in the house, needs for transportation to stores and

doctors.

This has proven to be one of the greatest tools that we can offer the citizens

of our City. If you would like more information feel free to contact me.

Andy Foote

Beaumont EMS Manager