Sean Eddy from Medic Madness, and fellow Uniform Stories contributor, has a new post up titled "3 Reasons EMS isn't ready to refuse care."
Go have a read, then come back for my comments.
Well, you're either ready to storm Sean's gates with your sharpened pitchfork or ready to defend him from what I've got to say on the subject.
Sean brings up some great issues that have been bouncing around EMS circles for decades. With the recent introduction of Community Paramedicine and the concept that we can, gasp, leave people at home in certain situations, EMS providers are looking to build on the outdated "Transport them all and let the ED sort it out" mentality of the 1970s.
Sean's 3 reasons are certainly worth discussion but I think he was very careful to sidestep the elephants in the room.
l'll address Sean's reasons 1 by 1, then give you the 3 real reasons we're not refusing care.
Sean's Reason #1 We're not trained for it.
I'll agree with Sean here on a handful of cases. I would argue that leaving a hyperventilating patient at home simply telling them "It's just anxiety" without addressing the symptoms we aren't ready for, nor should we be ready for. However, this skips over the other 99% of our calls. When a person has an injury or illness (or nothing assessed) and asks us "Do you think I need to go?" we should not be bullied into transporting by a management who only gets paid if the wheels turn and a nurse signs the chart. Honestly answering that patient's question and giving them the information they need to seek the care the need should be job #1. We are trained for that.
Sean's Reason #2 No Legal Protection
This is one of the urban legends of respond not convey, that somehow, somewhere, we're simply going to pull up, roll down the window, tell the person to just go to the ED and drive away.
There is not added liability in obtaining a refusal for a stubbed toe after telling the person that they don't need to go in an ambulance than there is in obtaining a refusal after telling them they should. Zero. It is simply changing the amount of accurate information available for the patient to make an informed decision regarding their are.
Sean's Reason #3 - We aren't designed to be the end point in care
Sean brings up an interesting point that we are not meant to be the definitive treatment for patients, that that is only done by MDs. Then I would call into question each and every refusal of service ever collected in the history of EMS. We should be, and currently are, the end point when necessary. Again, we're not talking about chest pain, stroke, abdominal pain of unknown etiology, those patients are all obviously in need of evaluation and we are not their end point. For the finger smashed in the door of the car we are also not the end point in care but that is no reason to REQUIRE ambulance transport to an Emergency Department. I can't fix the finger, surely we can agree, but there is nothing I can do beyond splinting and supportive care. In addition now we're sending an urgent care level patient to an ED, grossly over triaging "just to be safe."
Sean is a friend and don't take my comments about his concepts as disagreeing with him. He and I have discussed this topic repeatedly, as many of us have, and it is of course far easier to comment on ideas than come up with them. But we all need to be realistic about the REAL reasons EMS is not ready to refuse care.
Real Reason #1 - There's no profit in it
Oh, there's reduced cost in it, but no profit. Spending 30 minutes on scene for a refusal is not nearly as lucrative as a 30 minute transport. There is no increased liability, no increased training required, no fancy advanced classes or licenses, we just have to do what is right and allow the patient to make good decisions and seek out appropriate care in the community. But so long as insurance only covers transport, it won't happen.
Real Reason #2 - We don't understand liability
Leaving Erma Fishbiscuit at home isn't the problem, it's transporting her for no reason to an ED for no reason "Just to be safe" that is the liability. We remove needed resources from the system to satisfy decades of urban legends from the anchors about so and so who broke the rules and left someone home to die, but never about how no rigs were available for Mr Johnson yesterday. If the rules were broken and something bad happened, it isn't the rule that is the problem. We shouldn't be scared about letting patients make decisions. We inform, they decide, we do our best to get them what they need, we complete a chart and go away. Just like we do now.
Real Reason #3 - Adrenaline and turnover
No EMT wants to sit in Erma's house for 30 minutes making sure she knows where her medications are and when they should be taken. No Paramedic wants to sit with Mr and Mrs Jones and explain how their daughter's nebulizer works. They'd rather hit the lights and sirens, break hearts, save lives and take'em all and let the Doctor's sort them out, after all "We don't diagnose."
EMS is having a real problem taking itself seriously recently. I applaud Sean for making his list and putting it out in the public. We have a decision to make in the very near future and that relates to the future of EMS and I see it will divide us even further and I think it's a good thing.
Yes, I said dividing EMS is a good thing. More to follow.
-HM
Go have a read, then come back for my comments.
Well, you're either ready to storm Sean's gates with your sharpened pitchfork or ready to defend him from what I've got to say on the subject.
Sean brings up some great issues that have been bouncing around EMS circles for decades. With the recent introduction of Community Paramedicine and the concept that we can, gasp, leave people at home in certain situations, EMS providers are looking to build on the outdated "Transport them all and let the ED sort it out" mentality of the 1970s.
Sean's 3 reasons are certainly worth discussion but I think he was very careful to sidestep the elephants in the room.
l'll address Sean's reasons 1 by 1, then give you the 3 real reasons we're not refusing care.
Sean's Reason #1 We're not trained for it.
I'll agree with Sean here on a handful of cases. I would argue that leaving a hyperventilating patient at home simply telling them "It's just anxiety" without addressing the symptoms we aren't ready for, nor should we be ready for. However, this skips over the other 99% of our calls. When a person has an injury or illness (or nothing assessed) and asks us "Do you think I need to go?" we should not be bullied into transporting by a management who only gets paid if the wheels turn and a nurse signs the chart. Honestly answering that patient's question and giving them the information they need to seek the care the need should be job #1. We are trained for that.
Sean's Reason #2 No Legal Protection
This is one of the urban legends of respond not convey, that somehow, somewhere, we're simply going to pull up, roll down the window, tell the person to just go to the ED and drive away.
There is not added liability in obtaining a refusal for a stubbed toe after telling the person that they don't need to go in an ambulance than there is in obtaining a refusal after telling them they should. Zero. It is simply changing the amount of accurate information available for the patient to make an informed decision regarding their are.
Sean's Reason #3 - We aren't designed to be the end point in care
Sean brings up an interesting point that we are not meant to be the definitive treatment for patients, that that is only done by MDs. Then I would call into question each and every refusal of service ever collected in the history of EMS. We should be, and currently are, the end point when necessary. Again, we're not talking about chest pain, stroke, abdominal pain of unknown etiology, those patients are all obviously in need of evaluation and we are not their end point. For the finger smashed in the door of the car we are also not the end point in care but that is no reason to REQUIRE ambulance transport to an Emergency Department. I can't fix the finger, surely we can agree, but there is nothing I can do beyond splinting and supportive care. In addition now we're sending an urgent care level patient to an ED, grossly over triaging "just to be safe."
Sean is a friend and don't take my comments about his concepts as disagreeing with him. He and I have discussed this topic repeatedly, as many of us have, and it is of course far easier to comment on ideas than come up with them. But we all need to be realistic about the REAL reasons EMS is not ready to refuse care.
Real Reason #1 - There's no profit in it
Oh, there's reduced cost in it, but no profit. Spending 30 minutes on scene for a refusal is not nearly as lucrative as a 30 minute transport. There is no increased liability, no increased training required, no fancy advanced classes or licenses, we just have to do what is right and allow the patient to make good decisions and seek out appropriate care in the community. But so long as insurance only covers transport, it won't happen.
Real Reason #2 - We don't understand liability
Leaving Erma Fishbiscuit at home isn't the problem, it's transporting her for no reason to an ED for no reason "Just to be safe" that is the liability. We remove needed resources from the system to satisfy decades of urban legends from the anchors about so and so who broke the rules and left someone home to die, but never about how no rigs were available for Mr Johnson yesterday. If the rules were broken and something bad happened, it isn't the rule that is the problem. We shouldn't be scared about letting patients make decisions. We inform, they decide, we do our best to get them what they need, we complete a chart and go away. Just like we do now.
Real Reason #3 - Adrenaline and turnover
No EMT wants to sit in Erma's house for 30 minutes making sure she knows where her medications are and when they should be taken. No Paramedic wants to sit with Mr and Mrs Jones and explain how their daughter's nebulizer works. They'd rather hit the lights and sirens, break hearts, save lives and take'em all and let the Doctor's sort them out, after all "We don't diagnose."
EMS is having a real problem taking itself seriously recently. I applaud Sean for making his list and putting it out in the public. We have a decision to make in the very near future and that relates to the future of EMS and I see it will divide us even further and I think it's a good thing.
Yes, I said dividing EMS is a good thing. More to follow.
-HM
Comments
Fair enough, the pressures are a little different here: we don't get paid per patient. But I can't imagine that your EDs are any less packed than ours, and that's no good for anyone involved.