Patient Refusal Forms of Little Value

[Guest guest]

It is a multifaceted problem that has been created over the past 30+

years the system has been in place. I think the answer lies in the

middle of changing SOG's to not allow the medics to electively no-ride

people (BTW, there is a SOG related to " Mandatory Transports " but

compliance is sporadic at best) this would most likely require a

significant capital investment as well as the hiring of a bunch of

people to either place more MICU's in-service or make Paramedic

Engines/Truck Companies to supplement due to the volume of calls. Then

you have the QI part that needs to be greatly enhanced, again this will

require money to hire more people to do chart audits, ride along

evaluations etc etc etc, this is not likely to happen either. Regarding

the education part of the problem, I don't think it is the school (UTSW)

I believe it is due to new medics being partnered with old medics and

over time their bad habits either rub off or are forced on them and the

problem goes on and on. I know that DFR has recently got their own

Medical Director (just for them), he came for San Francisco I believe

and from what I hear is going to be a great asset for DFR and probably

the system in general. Again, this is not a bash of DFR, there are

other departments within the system that do the same things you just

don't hear much about them, this is a system problem in general.

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>

<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

>

>

[Guest guest]

Who is the new EMS med director for DFW from San Francisco referenced in a

recent post???

Kirk D. Mahon, MD, ABEM

6106 Keller Springs Rd

Dallas, TX 75248

[Guest guest]

I think it's interesting that I wrote that post before I knew about the

latest debacle from the Dallas system. Just goes to show what can happen when

medics " assume " that someone only has indigestion.

Gene

>

> Gene,

>

> We see those patients every day in the ED, and much of the time WE CAN'T

> make a diagnosis. So we get them admitted for observation and further testing,

> up to and including endoscopy.

>

> Randy

>

> R. (Randy) Loflin, M.D., FACEP

> Associate Professor

> Medical Director, City of El Paso EMSS

>

> Re: Patient Refusal Forms of Little Value

>

> 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.

>

>

[Guest guest]

Gene,

We see those patients every day in the ED, and much of the time WE CAN'T make a

diagnosis. So we get them admitted for observation and further testing, up to

and including endoscopy.

Randy

R. (Randy) Loflin, M.D., FACEP

Associate Professor

Medical Director, City of El Paso EMSS

Re: Patient Refusal Forms of Little Value

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.

[Guest guest]

Marshall Isaacs is the new Assistant Medical Director. Pepe is the Medical

Director.

Randy

R. (Randy) Loflin, M.D., FACEP

Associate Professor

Medical Director, City of El Paso EMSS

RE: Re: Patient Refusal Forms of Little Value

Who is the new EMS med director for DFW from San Francisco referenced in a

recent post???

Kirk D. Mahon, MD, ABEM

6106 Keller Springs Rd

Dallas, TX 75248

[Guest guest]

Gene,

I have look for the article you all spoke of about the patient with

abdominal pain being left at the house by DFD and later dying. Let me know

where you

all found this article.

Maxie

[Guest guest]

I know I am late on this one, but there are also some

ER docs that are so burned out they welcome refusals.

I know of very few doctors who would trust any

paramedic enough to allow an on-line refusal. The

times we have taken patients to the ER that really

didn't need to go by ambulance the ER staff to include

the ER doc, complain about why we transported the

patient. And on top of that they hold the patient on

your stretcher for hours until a bed becomes

available. We have been stuck in the ER for up to 5

hours with one patient. Now that ERs are starting to

triage and send non-emergency patients to an urgent

care clinic when they can't pay in advance for

services, we can weed out those patients. Hopefully

soon we too can refer these patients to an urgent care

center and hopefully even with on-line medical

control. So it's not always about the " lazy medic. "

Everyone here at some point in their career has pushed

a refusal. But what about when you have a service

that cuts down on the refusal rate by keeping that

unit up for calls until a transport is made and the

crews have to lie to a patient about their medical

condition just to get a transport?

Salvador Capuchino Jr

EMT-P

--- Kirk Mahon wrote:

> Henry,

>

> I totally agree with you. And I should have said,

> " I know one system that

> needs fixing. " I have had experience with several

> that do NOT have the

> issues discussed.

>

> Would anybody condone the following scenario:

> 90 year old lady has syncope and family calls 911.

> She comes to and is

> asymptomatic on EMS arrival. An ekg is done and

> since it is normal she

> doesn;'t come to the ER. What do you think just

> happened there?

>

> The official llights and sirens and badges would

> assure anybody that they

> are dealing with a proper authority to make that

> decision. However, syncope

> (especially in an older person) is a problem that

> needs a lot of detailed

> history, exam, labs, and monitoring. They need a

> physician evaluation. An

> ecg is not enough and it is a disservice to use it

> at the scene if your are

> then going to let people assume that the " machine

> that goes beep " says

> everything is ok and use that information to not

> transport....this is

> similar to the case mentioned in the article.

>

> If you are worried enough to do an ecg then you had

> damn well better

> transport. I am a huge believer in autonomy (not

> paternalism) but you need

> to make sure that the patient gets in the box. The

> real truth is, if they

> don't, there is a very good chance it is due to your

> communication about

> your assessment and the ecg that weighed in. That

> is dangerous.

>

> Kirk D. Mahon, MD, ABEM

>

> 6106 Keller Springs Rd

> Dallas, TX 75248

>

>

>

>

>

>