So what are the biggest things the courts take into consideration?

The number 1 consideration is did the EMS provider follow the given protocols?

I did not find a court case where the protocol itself was in question but that’s not to say it could not happen.

The second most important consideration is whether or not the patient was fully informed.
Remember: Condition Risks Benefits

The Young

If you have been around EMS for any amount of time you have herd many dispatchers say ‘baby not breathing’. You also know that 9 out 10 times you show up to find a panicked mother and a baby screaming his little head off.  Of course on the outside this baby looks fine but this baby had an ALTE, apparent life-threatening event. The baby needs a full workup to evaluate for possible causes of this ALTE, including reflux, seizures, RSV, dehydration and sepsis or worse.  Even though when you arrived there was no actual emergency, only minutes before there was.

The Old

Patients over the age of 65 years have a propensity to recontact paramedics and should be aggressively encouraged to seek emergency medical treatment. A study evaluated 431 AMA patients, 10 (2%) called 911 again within 48 hours. All 10 callbacks were made for a related chief compliant, and all 10 of these patients were transported (4 admitted to hospital, 1 died en route, 1 transferred to another facility, 4 discharged from the ED). Of these 10 patients, 7 (70%) were older than 65 years, compared with 17% of all AMA patients older than 65 years.

A few years ago I was called to the home of an elderly couple for a medical alarm around 2 am. The patient was walking to his bathroom and fell resulting in a small skin tear on his arm. His wife was unable to help him up. The patient stated he tripped and denied dizziness. We checked his vitals and ECG and talked with him about his history and how he as been feeling lately. Everything looked good to go. We offered to take him to the hospital but he refused. This call looked just like the typical fall and needs help up. We bandaged his arm, filled out the form and left.  A few days later he was admitted to hospital with increased weakness. My next shift we transported him to the nursing home and the shift after that we coded him.  Looking back I do not think that taking him to the ER the first night would have changed the outcome but what I took away from this is that it is import to know that you as a provider will probably see the start of a downward trend.  Sometimes what you deem as a trip and fall just might actually be a medical fall only a bit more hidden. Labeling these types of situations as a possibility will help you talk the patient into seeking further care.

The Misinformed

A crew is called to the home of a known seizure patient who lives at home with his parents. When the crew arrives the seizure was over but the patient was still disoriented. The family tells them his seizures are normally controlled with meds but they can not say for sure if he remembered to take his meds. This is not the parents first rodeo with this and they refuse transport. The EMS crew accepted the refusal even though their own documentation noted he only responded to verbal stimuli and was “disoriented/confused.” The crew documented that the patient refused care and that the patient’s father also requested no transport. The same crew returned about four hours later for an additional episode this time transporting. They noted that the patient had seizures earlier in the day and EMS did not transport per the father’s request. The crew spoke with the patient’s father later, and he stated that it had happened so often he thought it was the standard procedure for seizure patients to not be transported the first time the ambulance arrived at their house.

Lets assume this patient is a minor, otherwise I think everyone can see where this fails. The last statement is key because now the patients guardian is not technically fully informed.  Some patients might be under a false assumption about their condition or the standard of care.  The father thought that the EMS services protocols promoted a refusal for the first seizure. At least that is one possible argument for a plaintiff. If the crew in question had simply told the parents that the benefit to ED evaluation is to have his Dilantin levels checked they would have said ok. From a legal perspective if you do not inform the patient about the condition, risks and ED visit benefits then the refusal is not valid.

The Incarcerated

Most of the cases found while researching this involved people that are in police custody. Ems were not included as defendants most of the time but it is important to note that anytime you deal with an inmate or someone that has just been arrested the odds of at least having to appear in court are much greater. Make sure you completely document these calls.

Unable to Speek

In Green v. City of New York the patient, who was suffering from advanced amyotrophic lateral sclerosis (ALS) – or Lou Gehrig’s Disease – was unable to speak, but communicated by a system of eye blinking and through a laptop computer that spoke for him.  After experiencing an episode of respiratory distress due to a failure of his mechanical ventilator, his family called EMS to assist in ventilating the patient.  When he was successfully resuscitated, he regained consciousness and was allegedly determined to be alert and oriented on the scene (his residence).  By blinking his pre-arranged code for “no” and by typing into his laptop that he didn’t want to go to the hospital, the patient indicated his desire not be transported.  Nevertheless, allegedly without performing an assessment of the patient’s mental status, the paramedic in charge ordered that the patient be transported.

The federal appeals court ruled that failing to adhere to a competent patient’s wishes – where the patient could communicate but could not speak due to a physical disability – could constitute a violation of the ADA as well as civil assault and battery under state tort law.
full article – pdf

Refusing You

One court allowed a patient who specifically requested that no male health care provider view or touch her unclothed body during childbirth to pursue a battery claim against a male nurse who attended delivery. The patient’s physician had assured her that the male nurse would not see her un-clothed.

If a patients looks at you and tell you that he does not want you treating him, and you provide further aid even if the patient deteriorates to the point where implied consent would normally have been used you could be criminally charged.
full article

Did He Just Say That?

I know that this will make a medical director take a nitro pill but I found these studies so I’ll throw them out there.

Patient refusal after being treated for hypoglycemia

Repeat episodes of hypoglycemia are common; however, recurrences within 48 hours are not. There appears to be no difference in the incidence of recurrences and repeat episodes of hypoglycemia between transported and non-transported insulin-dependent patients, regardless of age. Given the high incidence of repeat episodes, paramedics and physicians need to emphasize the importance of follow-up.
full article

Opiate Overdose and Narcan

A study of 552 patients in San Antonio that received Narcan due to known opiate overdose and were not transported showed 0 patient deaths within 48 hrs.
A different study looked at heroin overdose and death within the following 12 hours and also found 0 deaths.
full article

One Last Tip (because I have seen it quite a few times): If you said “Your insurance will not cover it” you have failed. Everything you tell the patient should be pro ER evaluation.

The series will finish off with tips on documentation and the refusal form. Check back soon.