California Man Dies after Declining EMS

So I just read an article of a man who went to bed and never woke up after an accident where he refused EMS, and many thoughts ran through my head. This guy rolled his vehicle and suffered blunt force trauma to the head. He signed a refusal to EMS, and he was on his merry way. I have many questions. Was he restrained or ejected? What did he strike his head on? Did he lose consciousness? What was his true mental status at time of assessment? Was there a legitimate assessment done? If not, did he refuse even assessment? Was medical command consulted? Why do I ask? This is an unfortunate event that resulted in the untimely death of a very young adult. We have experienced or have potential to experience similar episodes. We need to ensure our patients don't slip through the cracks.

So, whose fault was it that he died? Well, inevitably, it was his own. He had drugs in his system while driving; he lost control of his vehicle, most likely from driving too fast; he was probably not restrained; and most of all, he refused medical treatment. Does that mean he was clearly an idiot? Maybe. Maybe not. Does this absolve the EMS crew of any responsibility? This is where I would like to have some more information to answer that. It could be that the EMS crew may or may not have done all they could have done. Am I discussing liability? I hate discussing liability. I would rather discuss good patient care and the prevention of premature deaths like this young man we are discussing. That should be our driving force. Not tort prevention. Anyway, that is neither here nor there. What I want to discuss is how can WE try to prevent an episode like this from occurring on one of OUR calls.

I asked about MOI. Rollovers are no longer criteria for trauma center transports since last year, though many systems still advocate it. However, with a rollover, more investigation needs to be done to determine the MOI directly to the patient. Did the vehicle flip multiple times? Was he unrestrained and hit he his head against the windshield or damage the interior of the vehicle with his body? The MOI is not a guidance to treatment nor mode of transport but the MOI may determine the appropriate destination hospital, such as LVL1 or LVL2 trauma center. It does not indicate need for helicopter. Distance to trauma center AND assessment findings do. It DOES mean you need to be more suspicious and focus your assessment on that suspicion, based upon the MOI. In this case, a complete trauma assessment, ensuring to pay particular attention on the head with a good neuro exam.
Someone at face value may appear benign, but upon closer evaluation, may show subtle signs or symptoms of a serious injury. So for this reason, we should not be so lax when responding to these calls even when finding the patient outside the vehicle visibly appearing uninjured. I know most of us, myself included, were quick to get a refusal in the middle of the night when our sleep was interrupted by some bozo who wrecked his or her car, and is found outside giving police information. I cannot emphasize enough the importance of doing a thorough assessment based upon the MOI, and this is a good case of why!

Let's say an assessment was performed and the assessment appeared unremarkable. With a MOI that caused blunt force trauma to the head, he should still be advised that further medical evaluation is necessary. Don't just tell him that. Patients will just tone that out. Explain WHY he should be evaluated at a hospital. Explain the process of TBIs in how their effects are not often readily evident and how people wake up, or, well, don't wake up-dead. Explain about forces that can damage internal organs like major blood vessels that can again, take time to manifest signs and symptoms. You may also want to get medical command to speak to him to explain the risks of not going to the hospital. If after all of that, he refuses ambulance transfer for whatever reason, try to get his assurance that he will seek evaluation at an ED ASAP. There have been many patients that I have evaluated who did not appear to NEED an ambulance, but should get further medical evaluation and treatment, who I felt easy allowing them to go by POV to the hospital. We all have. This guy, if he went by POV directly to the hospital, and got scanned, he may be alive today, although, I would advocate ambulance transport for him. ED MDs seem to give more attention to the patient brought in by ambulance than POV. If he refused to even go the hospital on his own, give him a list of signs and symptoms to be vigilant for as well as their significance. Of course you will instruct to call EMS or seek an ED if these signs and symptoms develop.

Now let's say further assessment WAS remarkable. You observe abnormal findings and realize he NEEDS to go to a trauma center. He refuses. You give him the speech and try to educate him. He still refuses. Now what? This is where it is imperative to get a hold of medical command and get the MD to speak to him. If he STILL refuses, you are pretty much legally off the hook. Otherwise, you would have to force him against his will, and they you are tempting kidnapping charges and violating patient autonomy. But you still have an an option or two. If police are present, try to use their authoritative demeanor to try and convince him. Of course, if the patient's condition does appear serious enough, there is also the option of taking him involuntarily, but only after medical command consultation. Otherwise, if you go that route, you better be prepared to justify it. The police will not usually get involved if the patient shows no altered mentation and unless you can can show it was obvious the patient would surely and quickly die otherwise, you may be asking to be sued. Therefore, I advocate to stay away from the notion of kidnapping. IF after all is said and done, and he still refuses, beg him to go on his own to the hospital, primarily a trauma center, and explain to him why.

Be sure to document well no only the scene survey and assessment results, but also ensure you state in detail all of your efforts to convince the patient to be transported to the hospital. Many states or agencies have their own special refusal forms, with a copy that goes to the patient. Ensure this is completed well, and if your narrative section is small on the refusal form, ensure your efforts to convince the patient are listed there. Ideally this info should be on the form signed by the patient and the copy given to the patient that lists your efforts. Attorney (and paramedic) W. Ann Maggiore advocates for a multi-tiered patient refusal form that applies to different types of contacts, such as the patient who needs to go but refuses, the patient who should be seen but does not necessarily need EMS and the person who does not become a patient at all, such as the fender bender you are routinely called to by bystanders but all parties involved are just trying to exchange insurance info and are denying injuries.

I know this goes without saying, but please don't deviate from your refusal protocols. The courts generally adhere to the concept of patient autonomy, and if the patient refuses, your adherence to your protocols and proper documentation are what will protect you legally when the patient or family try to sue you later, such as in this case.

So to summarize, the concepts are do a good scene survey to evaluate MOI to determine how to focus your assessment and appropriate destination hospital. We do an appropriate assessment based upon the MOI. Not a half-assed one. Those are the ones that burn us. Explain the risks, not just in vague terms, but really explain them. And get medical command involved if necessary. Just getting a signiture on a refusal form is not enough. So when you go home at the end of your shift, and you learn the patient who refused later turned up dead, your conscience should could be clear you gave your best effort for what was best for the patient. Then you can say for sure if he was really an idiot or not.

Just some interesting related literature:
Stacey Knight MStat, Lenora M. Olson MA, Lawrence J. Cook MStata, N. Clay Mann PhD, MS, Howard M. Corneli MD and J. Michael Dean MD, MBA, Against all advice: An analysis of out-of-hospital refusals of care, Annals of Emergency Medicine, Volume 42, Issue 5, November 2003, Pages 689-696

S.Mulholland, B.Gabbe, P.Cameron, Is paramedic judgement useful in prehospital trauma triage? Injury, Volume 36, Issue 11, Pages 1298-1305

Robert P. Pringle, Jr MD, Donna L. Carden MD, Feng Xiao MD and Derrel D. Graham, Jr MD, Outcomes of patients not transported after calling 911, Journal of Emergency Medicine Volume 28, Issue 4, May 2005, Pages 449-454

Lynn K. Wittwer, MD, MPD, Refusal of Medical Assistance, slide presentation


Adam Thompson, EMT-P said...

This is one of those topics that makes us all feel an unease. I think we have all had to get a signature on a refusal that we didn't want to do. It is so important to do and document that full assessment. Some of the key points our agency concentrates on are as follows.

1. Is the patient an adult or emancipated minor?
2. Is the patient mentally capable of making their own healthcare decisions?
3. Has the patient been made aware of possible consequences of transport refusal?
4. Is the patient aware they may use our service after this refusal?
5. Who is the patient being left with?
6. Is the patient hemodynamically stable and without obvious significant injury?
7. What is the patient's plan for treatment if any?
8. Document how many times transport was offered.
9. Document full assessment with vital signs
10. Have witness sign refusal

One of the things I like to do when I feel completely uncomfortable with a refusal is call the doc. I have yet to have a physician give me orders to take a patient against their will, but it shows that I have exhausted all options.

In this field we become somewhat of salesmen. I think many of us know how to get a patient to go, or even refuse transport based on the way we phrase our questions.

Get that refusal phrases:

"You want to go by ambulance or have one of your friends here take you?"

"Well, we have to tell everyone that they should go."

"So do you want to go to the hospital by ambulance for this?"

"Well if you are going to go with us, we are going to have to put you on that big board and strap you down."

"It is not quicker to go by ambulance, that is a common misconception."

Urge transport phrases:

"Okay so lets go to the hospital and get you checked out."

"We don't have all the equipment they do at the hospital..."

"I want you to realize that you could possibly die from this."

"Have a seat on the stretcher"

That last one is huge. Once you get the patient on the stretcher, they are much more inclined to go with you.

Other things to remember:

-If the patient wants to refuse transport because of treatment, they can just refuse that treatment. ie. IV, backboard, C-collar, etc..

-Utilize those worried family members to help you convince the patient.

Shaggy said...

I could not agree more. Our refusal form has yes/no check-off boxes, and if there is a "yes" checked for any of them, such as the points you mentioned, you must call an MD. Sometimes it is a pain, but in the long run, it is better for the patient and protects your hide.