A few weeks ago I was sitting around the station talking to a couple EMT’s about some issues that they had with the translation of a “lift assist” or public assist into a patient refusal. It was not so much a personal problem since, as one of them put it to me, “If I touch them, I get a refusal” but it was more the actions that they had seen some of their coworkers take to minimize their own paperwork. Interestingly enough, the debate of “what is a patient” and “who gets a refusal” was a long standing debate that I had with some people during my years as a supervisor.
The scenario we most commonly encounter is a simple one. It is like that old Life Call from the 80’s. Mrs. Fletcher falls in her bathroom, pushes her pendant and moments later, she is telling someone “I’ve fallen, and I can’t get up!” EMS, the fire department, the police department, and whoever else gets called is on the way to her in no time. A few minutes later the crew gets on scene and finds Mrs. Fletcher as they would expect her to be: seated on the floor unable to get herself off the floor and back in her chair. The responsible ambulance crew gets on each side of her, hooks their arm under hers, puts her back in the chair, and they’re out the door without another word spoken. The paperwork is simple, and they’re back in service.
That is how it happens, right?
If they were my ambulance crew that better not be how it happened. Anytime Mrs. Fletcher finds herself on the floor it is up to us to at least make an attempt to find out how she landed there. The first question that should be asked is “what happened? Did you trip? Did you get dizzy?” Follow that up with another simple one: “Are you hurt?” I know, it seems like it would be a no-brainer, but that is not always true.
You need to get a look at the medications that these patients take. Is there a beta-blocker in there? Are they a diabetic? These patients need at least one full set of vital signs taken. Are they hyper or hypotensive? You do not need to spend an hour with these patients. You do not need to do a twelve lead or start cutting clothes and exposing what you might think is an injury unless, of course, your index of suspicion is high enough to do that, and if so, a refusal should not even be on your mind.
The whole process and the whole encounter can take less than fifteen minutes, and quite often less than ten. The fact is though, these patients (and yes I call them patients) warrant a simple once over. Every shred of geriatric care and assessment education points towards it, and leaving them without giving them that simple evaluation does them an injustice and violates everything we should stand for as EMS providers.
Now, the most common argument that I got when I would have these discussions with people who might not have done the right thing was, “so am I supposed to get a refusal signed on every single person in a car accident?” Not exactly. There is a difference. Mrs. Fletcher has been identified as someone who needs your assistance. That group of college kids standing on the side of the road after their car accident, however, have not. Asking them simply, “Is anyone hurt?” Can often be enough to cover you and figure out who does need further evaluation and who does not.
Personally, for me, there are four types of people I get refusals on when they refuse my transport or care. The first one is obviously someone who identifies themselves as a patient. Someone who tells me they need my help. They get an assessment, and if they don’t want to go to the hospital, they sign a refusal. The second is someone who someone else identifies as a patient. Like that little old man whose daughter calls 911 for because he’s been having trouble breathing. The third is someone who is obviously in distress, like someone who is unconscious or has an obvious visible injury.
The final patient though is the elusive grey area. Even the newest EMT knows what I am talking about. I mean though patients that make that sixth sense go off. That guy who was in that really nasty wreck and is walking around just saying that he is fine, and refusing to let anyone touch him. That is the patient that we need to press, and at least say, “Sir, if you’re not going to let me check you out, at least let me get some information from you.” Some of them are going to be incredibly resistant and defiant, but we need to do the best that we can, and then document that we did what we could.
The sad fact though is that I have to write this post at all, and its disappointing for two reasons. First of all, me sitting here and typing all of this out means that there are people out there who are failing to put their patients first and do everything that they can and should for them. That alone is disappointing. Secondly, this paperwork is required because we live in such a litigious society that we need to think about the liability, both personal and professional in nature that our documentation puts us under.
The bottom line is this: did they fall? Are they still on the ground? Just give them that quick once over. You never know what you might find.