“It’s A Trap!”

Funny that JEMS would post this, and it be written by a close friend of mine Chris Kaiser….

Cause I was thinking this exactly same thing this morning as I ate a light breakfast and drifted off into a short nap to recover from the beating I took on the ambulance last night.

The reason I call this post “It’s A Trap!” is not just a tribute to Justin Schorr and his addiction to all things meme, but because we often have patients that ask us questions when attempting to decline the need for medical treatment or further evaluation, and usually those questions are traps into asking us what OUR opinion of what they should do about their own welfare. I mean, that is why they called for an emergency service, right?

The problem is that we can’t “legally” offer them our opinion, part of the idea of informed consent and informed decision making we push so hard for in patient care is that they make the choice based on what they feel is appropriate. But how can they gauge what is appropriate? They rely us to tell them! It becomes a Catch-22 in some systems where the “transport everyone” mentality reigns but their condition in our experience and limited diagnostic tools tell us that they can wait to see a doctor in the morning or not need any medical intervention at all. So we are stuck, looking like a blabbering idiot, trying to explain to them that we are the people to call in an emergency, but we can’t tell them what’s wrong or what they should do about it. Which, I believe and have seen, degrades that person’s confidence in us rather quickly.

Case in point: I responded to a 26 year old man that “woke up panicking” and felt that he couldn’t catch his breath. So, thinking of all the different causations it could be, he activates the 911 system. We arrive to find him walking outside to us as casually as could be and in no distress, we perform a basic assessment and find nothing abnormal. Then we are asked “The Question”: “do you think I need to go to the hospital?”

“It’s a trap!”

Of course, at 0230 in the morning my answer was almost a hearty “hell no!” I saw the trap rather quickly, as did my Basic EMT partner. We explained to him that we performed a brief medical exam, and that while all the basic stuff that would indicate a life threatening emergency came back normal, there are things that even we can not detect that would be detected at the hospital if they felt it would be warranted. After trying to get him to a decision point, we ended up having to tell him point blank that he must make the decision himself based on what we can tell him right now and what he feels is right and necessary to proceed. He declined.

What he expected us for us to show up and tell him what to do. That is not “informed” anything. I’ve been in this debate before about what we feel is appropriate and what the patient wants and desires. Are we legally able to override a patient’s desire for treatment of their choice (or not, as in this case) based on what we feel is appropriate for them? Not in this country. If we take someone somewhere where they don’t want to go against their *competent* will that is the definition of kidnapping. If we are summoned to a scene where we had a duty to act (which means transport, which is ALL EMS calls practically) and fail or refuse to act (transport) and cause damage, that is negligence. So how to avoid the negligence issue and NOT kidnap them? We give them a choice based on medical fact at the time of exam and if they are competent to do so, let them decide. If they go against the medical advice, they attest to that fact on a legal document. Some services call this an “AMA Form.”

AMA means “Against Medical Advice.” Although, one of my old field training offers said it should be “Against MY Advice.” But how often do we interject our own personal opinions on what is best for a patient based on time of day (BIG one), experience, etc, etc, etc? I don’t think it happens very often. I think we may scare a lot of people into going using the Boogey Man or the Grim Reaper but when we get asked to give an opinion, it gets a bit sticky.

Avoid the trap or giving your personal opinion. Make sure what you’re offering up when they ask is based on the factual condition at the time of exam.

Check out this explanation on Negligence and the EMS Professional