Engine Company EMS: The Refusal

Ambulance

By Michael Morse

Let’s face it: There are times when an engine company response to an EMS call is needless. Conventional wisdom tells us to treat and transport all persons who call 911 regardless of the severity of their condition. Successful lawsuits involving refusal of transport are incredibly rare, but possible. As providers of medical care in homes and in the street, we are considered the gateway into the healthcare system. That system, especially at the emergency level (including EMS) is increasingly overburdened. The people providing care are overworked, underappreciated, and overwhelmed. Confronting a caller who believes that using 911 for routine a minor injury or illness care is prudent often does not end well. Doing so creates public animosity, headaches for the crew and, as we are likely to be reminded by our employer, a loss of revenue for the service.

It is difficult but essential to remember that we, as providers, are not powerless players in a system that may be teetering near collapse. It might be easier to go along to get along and await the ambulance to arrive so we can wash our hands of a person looking for a ride to the ER. But in the big scheme of things, that method of operation essentially abdicates our responsibility and adds to the burden on the system. We are responsible for protecting the public. Part of that mission includes being able to respond to emergencies in a timely manner. Waiting for a unit with transport capabilities to clear while performing CPR or assessing and treating trauma has become business as usual in many systems. It should not be that way. Obtaining a patient refusal when appropriate might not solve the entire problem, but just may be the beginning of a chain of events that will ultimately end in a unit being available when it is desperately needed.

There are two very different potential refusal situations:

1. A patient needs treatment and transport but refuses.

This is the run where all of our training and power of persuasion is needed. We are trained professionals and can recognize life-threatening injury and illness. We have equipment and assessment skills that support our opinion. We have experience, compassion, and intelligence. And we have an ambulance on the way. If the patient is assessed and deemed competent, proper and thorough documentation is essential.

JEMS: Know When and How Your Patient Can Legally Refuse Care

2. A patient demands treatment and transport but does not need it.

A thorough evaluation including vital signs and any additional testing (blood glucose, EKG, etc.) is imperative before suggesting treatment options that do not include transport to an emergency department. A checklist may be helpful. After the evaluation, explaining to the patient that their vital signs are within normal limits, there is no deformity, no bleeding, no discernible threat of imminent death, disability, or disfigurement that would necessitate emergency transport may or may not dissuade them from using the service you provide. Sometimes a patient simply needs reassurance or a competent person to soothe their fears. They may need medical attention, but transport to an emergency department may be the least appropriate way for them to access care. Providing alternative solutions to their problem helps. A walk-in clinic may be far more affordable with a shorter wait. Perhaps a call to their primary care physician would be wiser, and may even be exactly what the patient wants and needs. Documenting your findings and including your recommendations in your patient care report does not guarantee immunity from repercussion should the patient file a complaint, but will certainly help your case if a call is ever reviewed.

There are patients who will never accept anything short of transport to an emergency department in an ambulance. For those patients, we have no options. Often, for the sake of your own sanity, it is wise to acquiesce. Engaging in an argument with somebody who called 911 inappropriately is both useless and unprofessional. We are, in effect, street soldiers. Policies are made by people above us; our best intentions may well be ignored when a complaint from a citizen is filed. Self-preservation is just as important as patient care. We need good soldiers to remain on the streets.

Michael Morse is a former captain with the Providence (RI) Fire Department (PFD), an author, and a popular columnist. He served on PFD’s Engine Co. 2., Engine Co. 9, and Ladder Co. 4 for 10 years prior to becoming an EMT-C on Rescue Co 1 and Captain of Rescue Co. 5.