The Art of Refusal

A scenario, if you will:
You, as a newish Paramedic, are dispatched to a weekend party for a gentleman who fell from an all terrain vehicle at very, very, low speed. You arrive on scene shortly after a police officer that has previously advised that your scene is safe and the patient is easily accessible.

You arrive on scene in all your 0200 glory to find a 50ish year old male complaining of minimal right shoulder pain. The patient is ambulatory with a steady gait, immediately advises you that he does not wish to utilize your services, and politely tells you to go back to bed...Not so fast. A quick examination of the patient’s mental status reveals an odor consistent with the consumption of ETOH. Further assessment reveals no injuries, no medical concerns, and a completely normal set of vital signs.

Does this patient have the right to refuse EMS services?

-Refusal, are you crazy?

This patient is intoxicated. There is no way that this person has the mental capacity to refuse. At the very least this patient needs a disgruntled medical control physician to evaluate his decision making capability and decide for the Paramedic what should be done…after all it is his license. The fight is on. In order to transport this patient he will have to be issued an ultimatum by the men in blue, which will make him very unhappy. Now this patient will need to be handcuffed to your cot, officer at his side, with you making a futile attempt at assessment. When you arrive at the ER the patient is even more agitated than he was ten minutes ago. Now the patient has an ambulance bill, ruined his night, and is thinking about suing you, your service, and your mother.

An alternative approach…

-Yes, let him refuse.

This patient is intoxicated. Enter the modified Folstein mini-mental exam, a multiple question exam evaluating multiple facets of cognitive function. It’s very simple, you ask the patient some questions and the more the patient answers correctly the more competent the patient is to make decisions. So…fill out the exam, if the score meets the minimum of the exam, let the patient refuse. More work? Yes. Easier to sleep at night? Yes. Bottom line is that good patient care when utilizing a refusal dictates some sort of mental examination. We, as EMS professionals, need to act in the best interest of the patient and do our very best to defend against liability that may jeopardize your livelihood and also the livelihood of the people you work for, and your family. The patient care refusal is only as good as the provider completing it.

The iMedic

No...I'm Really Sick

Hello again. Time has passed since my first post here and I thought it was time to get back on the horse and start riding. For the past few weeks I have been evaluating this idea of EMS blogging with mixed emotions. When I sit back and be who I normally am, I feel like there is no point to this. There is a part of me that says all I am going to gain by blogging is polarizing opinions of fellow providers…Mrs. iMedic says that my justification for not writing is crap and that I should stand for something. While I don’t intend to be the “in your face” blogger like some of the other professionals in the EMS blogosphere, I do have my opinions. My opinions are just that, my own. My experience pales in comparison to some of the famous bloggers such as the Happy Medic or Medic 999 but I do feel that I have some insight to share.

Enough with me trying to convince myself that it is okay to blog...On to the real post.

I am a paramedic at a smallish primary 911 service and in my opinion it is a fantastic place to work. Every week and seemingly everyday people call in sick. Now I understand that employees are given sick time as a benefit to being a full time employee but wow. It absolutely amazes me how many people call in sick to work. Why? We are paid to come to work, check in our truck, and aside from some tasks that are assigned, aren’t expected to do anything. We are paid a decent wage to drive around, take care of people when needed, and basically do things at our own pace. Is this hard? No. With all of this rambling I feel I need to admit that I have called in sick once or twice in my career but I definitely try to keep it honest. It is not my intent to jab, personally, the folks who are more likely to call in sick but this is intriguing.

Research: A magazine in the U.K. reports that public sector employees are more likely to go to work when they are actually ill. The same magazine reports that more days were lost in the public sector due to illness. (view link below)
http://www.hrmagazine.co.uk/news/993443/TUC-reports-public-sector-staff-likely-work-when-ill-less-likely-call-sick/ (read closely)

So...the questions for debate…
Why do people call in sick to work when they are not sick and are public safety employees more likely to call in than the employee in a private sector job?

the iMedic
#CoEMS

God's Work

So, as my inaugural post in the EMS blogosphere I thought I would take a minute to say congratulations to myself on landing a great job with a very respectable 911 service. After several years of doing the volunteer, private, slash interfacility work I am onward and upward to lights and sirens, smashed up cars and super sick people. (Insert own cliché here) As I look back at the time spent doing hospice transfers and returns to nursing homes I wonder how much has this work worked for me? After much thought I conclude that this experience has made me a better provider than I would be if I had started in the busy 911 setting.

Everyday I hear coworkers drone on about the trials and tribulations of doing “you call, we haul” work. (Myself included) This is important stuff. It is hard, very hard to see the forest through the trees with interfacility work but the level of personal satisfaction is immense. The time spent with patients experiencing the last seconds, minutes, hours, or days of their life is some of the best patient care experience available. I present the following reasons why transfer service ambulance experience is the best, years of education and thousands of dollars can buy.

1) Transfer patient’s are sick. (especially patient’s being transferred from an outlying facility) Providers must be comfortable with unstable patients and must be confident in their ability to get them to their destination alive.

2) Conversation is difficult. EMT’s and Paramedics must learn to be conversationalists. During a two hour transfer, boredom is the greatest threat to your patient. Providers must learn to carry a conversation or master FlightPlan for the iPhone®. (not me)

3) Diplomacy is not a strength for EMS providers. Are we nice to nurses? Are they nice to us? The transfer process can make a good day bad for any provider, it is no trouble to discontinue an IV or put away monitor cables so the room is ready for the next ER patient on a busy day.

4) Hold a hand. During my field experience as a Paramedic student I witnessed a very seasoned and “hardened” provider grab an 88 year old lady’s hand an hold it all the way to the hospital. No treatment was necessary but after holding this person’s hand it was obvious that the patient was at ease.

5) Treat everyone as you would treat your mother. There is no room for rude providers. I have witness providers be “short” with patients and I ask you, what good does that do? This is our career and we need to act accordingly. I will say that I, on one or two occasions, was rude to a patient. Granted, the patient was difficult but that is no excuse. The ride is usually short so be nice.
This entire list is purely rambling and I most certainly do not know it all. But as I enter the world of 911 I will most definitely keep this information in the earbuds. (along with the EMS Garage)
God Bless