You are dispatched to a reported motorcycle down in a trouble area in your district. On arrival you find a single motorcycle has impacted the side of a big rig tractor which was turning in front of him. He is laying supine, helmet removed prior to your arrival and is alert and oriented.
The rider states he was travelling at 20-30 mph and pulled the brakes when he realized he was not going to make it around the truck. The skid marks leading up to the truck match that story and you begin your assessment.
Deformity to the left clavicle, self splinted and pain on palpation to the left flank are noted with no flail segment noticible on palpation or observation. No other trauma is noted and the helmet is pristine.
As you begin to cut the leather jacket, after convincing him it will not be a good idea to pull it off considering the injury, he pulls rank.
"Ease up kid, I'm a Doctor. Just do what I say and I'll be fine."
You pause a moment and consider his statement. After the first try to move his arm ends in screams, he reluctantly agrees to cut just only the area needed.
As C-spine precautions are applied he bats them away and adds another gem, "I'm not going to Regional Trauma, take me to Saint Farthest."
Saint Farthest is a local ER, most often staffed with a general practitioner doing their rotation. They have no surgical capabilities and the last time you took a patient there with a decent laceration there was an argument.
The patient identifies himself as a trauma doc and doesn't want to bother his co-workers.
He'll agree to the collar and board if you agree to take him to St Farthest.
What do you do?
You make the call.
Read through the comments, the click HERE to see what call I made.
Comments
In this situation, he would fall under the "rider separated from vehicle" criteria under our trauma activation protocol. So naturally, we would have to take him to our local trauma center. However, being that he is alert and oriented, he DOES have the right to refuse transport to that hospital. The fact that he is a physician has nothing to do with it. He's a patient at this point, not a doctor.
I would do my best in this scenario to convince him to allow transport to the trauma center and explain the risks of refusing. Once he stated that he understood the risks and STILL wanted to be transported to St. Furthest, I would have him sign a "Trauma System Refusal Form", or a standard "AMA" if your system doesn't use that form. I would probably get a witness signature from a police officer on scene as well.
When I rolled into St. Furthest, I would let him do all the explaining.
I wouldn't call the receiving facility, they'll be so pre-loaded with WTF factor X if they hear they're now a trauma center....
I'd call my field supervisor (RC1, perhaps, ?) to help soothe the irritation.
"looks like his gcs is 12 now."
As for the Kidnapping comment, my Medical Director has always said you're going to have a much easier job justifying your actions by saying "I felt this guy needed a trauma center for XYZ" than you would saying "He assessed himself, and felt that he didnt need it."
The way I see it, when you're involved in the accident/incident, you lose all ability to properly assess yourself if you're a trained individual. Its too bad our training couldnt include that lesson...
I would have documented with a refusal and through the trauma center. Reminded him that the private ambulance that took him to the trauma center next was going to hit him up for $2000 and took him where he wanted to go.
Of course I say do your assessment, but a patient proven competent can refuse any and all care. All you can do in those cases is present alternatives. I know this from personal experience, and we deal with issues like these without supervision all the time. If they attempt to refuse care you must assess their mental capacity to do so. Score >21? They can decide their own fate.
My medical director relayed a story to me one time about a patient that walked into his ED with an active MI and they were going to transfer him out to a cath facility, and he declined any care and signed out AMA. They pleaded with him to stay but he still left. Point being, just because we know that they are endangering themselves by not seeking appropriate care when they should doesn't mean that if they are competent to decline such care that we can stop them.
I myself have had a similar situation you describe except the patient wasn't a physician, and was competent, and wanted to go to one hospital and that facility only. I just told the hospital that I explained the guidelines, recommended a more appropriate facility, they declined and are competent to do so, and we will see you soon.
Treat the patient, not their (hypothetical) lawyer. I can assure you, the conversation will go something like this:
Patient: I want to sue my EMT!
Lawyer: Why?
Patient: I crashed my motorcycle wanted to go to St. Farthest, but s/he took me to Regional Trauma instead!
Lawyer: I see. Well, according to these protocols I found online, the EMTs are supposed to take motorcycle crashes to Regional Trauma. Based on your location, it was also much closer than St. Farthest. What was your reason for wanting to go to St. Farthest?
Patient: I work at Regional Trauma and didn't want to bother my coworkers.
Lawyer: *click*
In reality St. Farthest will put his clavicle in a sling, arrange next day follow up with an orthopod for possible surgery and, if his chest and abdomen CT are clear, send him home with a Vicodin prescription. Even if they find something on CT they can ship him out - he'll feel a fool having delayed but he is a grown-up and clearly had capacity to make informed consent on his preference to not go to Regional Trauma.
........ooops! ...............time for my meds
"Are you willing to go to Regional Trauma if we don't immobilize you?"
Patient goes to trauma center and there's no hocus pocus immobilization done (where, again, are the studies showing immobilization prevents secondary spinal injury?) and the patient is spared additional back pain and skin integrity problems.
Is it ever right to override a patient's own decision (provided capacity is present) for their own good? Would you like to be in a hospital and the physician is ordering test, procedures, and medications, but won't tell you what they are because it's "for your own good?" More importantly, where do we stop? Ok, sure, the AMI really should go to a cath lab.
What if Regional Trauma is a hell-hole? How many people would willingly go to King-Drew Medical Center before Joint Commission yanked their accreditation? I'm sure every system has that one hospital that you want to avoid like the plague. Do the EMS providers have a right to haul you there anyways?
What about other more cloudy medical decisions? Do EMS providers get to ignore DNR orders because the patient doesn't look that sick? What about situations where the patient (or parent for a sick kid) has a long term condition and has become a self styled expert on it? Do we ignore their input at all since the all-knowing paramedics know what's best? Paternalism is a dangerous slippery slope even when the provider-patient relationship is measured in years. However, we're talking about a situation here where that relationship is measured in minutes, at most in hours.
If the patient is CAOx4 and truly understands the risks of refusal, I'll call command at Regional Trauma and have their command doc actually talk to my patient after I paint the picture.
Then MotorDoc either agrees to go to Regional Trauma, or his refusal is documented on a recorded line.
Why is it that healthcare providers make the worst patients?
....Or slam in 20mg of MS and 10mg of Versed for "pain control" and once he's out of it transport him to the hospital. (I'm kidding.....mostly)
Kidnap is right up there with liability as the most misunderstood terms in EMS.