Sign the Refusal Form, Ask Them To Leave, and Drive Him To the Hospital


One Saturday several years ago I got a phone call from my mother, who was in my home town 400 miles away.  She had called 911 for my grandfather, who was entering his later stage of dementia, and had passed out.  In the background I heard a paramedic from the company I used to work for explain that his blood pressure and EKG were normal, that he did not need to go to the hospital in an ambulance, and that it was safe to drive him themselves or follow up with his doctor on Monday.  My blood pressure shot up.

Even if my grandfather’s mentation was consistent with his baseline, he was past the point of being able to provide a reliable history.  He could not have communicated that he had chest pain or palpitations before he passing out.  There are also a lot of bad things we can’t check for in syncope patients.  Electrolyte imbalances, medication errors, and sepsis can cause people who “look fine now” to decompensate quickly.  To proclaim that it was safe to leave my grandfather home after a five minute assessment and one set of vital signs was negligent.

I could have asked to speak with the paramedic, remind him of these things, and gently recommend that he at least transport him on the monitor.  Vital sign trends and serial EKG’s are valuable for patient’s like this, but if the paramedic was too lazy to recommend that he be transported at all, he was probably too lazy to do this too.  I’d rather have my parents drive him.  He was discharged later from the ER after blood work and observation.  While the system didn’t fail him, he deserved better from it.

Unfortunately coerced refusals were common place at that service.  I was amazed at how confident my partners appeared when they told people they did not need to go to the hospital.  I am ashamed that I engaged in this myself.  Sometimes it was done under the guise of doing what’s best for the community – such as getting a refusal to stay available for “real” emergencies.  Now I realize this was in the interest of us going on sexier calls, and not in the interest of the patient we were with.  We were never taught about who did not need to go to the hospital, and I do not teach any of my students this now.  The more I learn, the more I realize how limited our knowledge base about diseases is.  Now I always recommend people go to the hospital, and rarely release patients to a BLS unit to get them there.

When my aunt (his daughter)  was injured from a minor fall in Fort Worth, TX last year, she had a wonderful experience with the MedStar paramedics.  They took extra time on to start an IV and give her pain medication before moving her.  I am sorry that my family in my home town had the opposite experience with the people who showed up for my grandfather.  We have the potential to do so much to help people, if we only apply it.  I am sad to say that if someone from my hometown calls to ask if they should call 911 for something, I would probably tell them to just drive to the hospital.

Comments

  1. lorraine okie says:

    Thank you for your Expertise and commitment to Educate the Public. This is a much needed Resource and I will Share with my FB Family & Friends.

  2. This is the bane of many EMS agencies. I would imagine the medic did a lead 2 ECG and pronounced your grandfather “fit for POV (privately operated vehicle)”. A study on this very issue was completed in Dallas a few years ago. It was found that patient refusals spiked near meal times as well as near the end of the shift. I suppose only stable patients call during those time.

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