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Liability – Part II

Hidden in the controversy that surrounds “customer service” in Fire and EMS, I reminded you of the two distinct definitions of the word liability and how 99% of people in this line of work misuse it.

Much like patient has two completely different definitions, liability has always been explained to young EMTs as something pertaining to them defending their license or certificate in court for doing something wrong.

But when we transport Bubba Fishbiscuit because he’s out of Xanax at 11pm, driving past 2 24 hour pharmacies, we are ignoring the real liability, the next person who might actually need us.

In my rose colored world of a successful EMS 2.0 launch, the Paramedic at the scene directs Bubba to the pharmacy, cancels the ambulance and makes a note to follow up by phone in the morning to make sure Bubba gets his meds refilled on his own without activating 911.  That releases the service from the perceived liability that Bubba *might* get angry, *might* complain, and *might* make noise at the next City Council meeting.

I say let him.

Let’s start to hear these folks explain their actions at a City Council, shareholder, union meeting or court room.

Let them describe the inconvenience of having to wait a whole 6 minutes for a lights and sirens response for a prescription refill they have known will be gone since the moment it was filled.

Cry about not having a car, bus fare or a friend to drive them.  Do it.  Then let them describe the treatment given to them by the EMS crews.  Every detail of the extensive advanced life support service rendered since the 911 call was placed.

Not going to happen?  I know.  Your Chiefs and managers are too worried about a perceived wrong doing that is actually a response to a wrong doing.  Following me?

I can go on and on for weeks about persons abusing 911 as their personal taxi service, but today let’s discuss the stranded.

I define a stranded patient as one who has been passed over by the “system,” both private and public and is now 100% dependent upon EMS to get them to appointments, refills, dialysis, etc.

These folks need a service that exists in only a few communities.  A van.

“No!” the bean counters are screaming, “That’s a huge liability!”

He means the part of the definition of liability that pertains to a responsibility or duty.  But he is actually referring to the second, more accurate, definition of liability, a hindrance.

Persons who call 911 and demand a level of service below the standard of care are a hindrance to the efficient running of an emergency service, not a responsibility of emergency workers.

But this is where that other question pops up, isn’t it?

Is EMS a public safety agency or a public health agency?

Really depends on your system and how you handle calls for service that have no medical component.

If you will take anyone for any reason, I say you fall into the public health model.

If your service focuses on lights and sirens emergencies, take a seat in the public safety model.

But in every system there are persons creating actual liability by draining highly trained, not to mention expensive, resources to do the job of a clerk, aide or driver.

Putting a van on the street that can be called and arranged for these kinds of folks can not only save money, but lives.

I can hear some of you now, “Vans save lives? Prove it!”

I can’t, but I can make the inference that more ambulances available for emergencies means a shorter response time and early intervention is key in survivability in the one case we can trend with certainty: SCA.

Let me give you a situation and let’s see what you would do.

You are dispatched to a street corner in your ALS ambulance for a reported asthma attack.  When you arrive, a group of young women, in their twenties, are all texting away on the newest of phones.  As you approach, one of them produces an albuterol inhaler and, without a hint of respiratory trouble, tells you she is out and wants to goto the hospital to get more.

If your answer is “Get in, let’s get this over with” you are accepting the perceived liability and putting your community at risk.

If your answer is “Can one of them take you to the pharmacy?” you are leaning in the needed direction, but unless you can arrange something, you’re about to start a losing fight and will, in the end, be taking her.

If, in the off chance you are lucky enough, you respond by telling her your service does not give rides to refills, then arrange for her to seek out the proper assistance, I want to know about your system.

As you load the girl into the back of the ambulance and begin your assessment, the next person who may actually need you is now at an increased risk of poorer outcome.

Unless, of course, one of her friends decides she wants a ride too.

Ask your Medical Director the definition of liability and why we assign it to the least of our worries and roll the dice on the rest.

And, again, follow your local protocols.  Which likely means you’ll answer “get in.”

Agree? Disagree? Have something to add? Why not leave a comment or subscribe to the RSS feed to have future articles delivered to your feed reader?

17 thoughts on “Liability – Part II”

  1. Happy, how are we who aren't yet providers going to be able to make a difference? From my limited experience as a Basic Student so far, no one seems to respect the opinion of someone that hasn't actually ran a call yet. I agree that we don't know how things work “on the street” but even just with the scenarios that you have presented, I think a layperson would be very hard pressed to justify an ambulance transport of those patients, yet they seem to expect it… why can't the EMT or Medic on the rig that responds to those type of call tell the patient to “get lost”? why is liability such a major issue?

    ~Brad
    @EMTGoose

  2. Happy, how are we who aren’t yet providers going to be able to make a difference? From my limited experience as a Basic Student so far, no one seems to respect the opinion of someone that hasn’t actually ran a call yet. I agree that we don’t know how things work “on the street” but even just with the scenarios that you have presented, I think a layperson would be very hard pressed to justify an ambulance transport of those patients, yet they seem to expect it… why can’t the EMT or Medic on the rig that responds to those type of call tell the patient to “get lost”? why is liability such a major issue?

    ~Brad
    @EMTGoose

  3. I live in an apt complex with older residents, all of whom are SUPPOSED to be living independently with only minimal health problems. Too many of my neighbors call 911, and get full response, for light-headed feelings, arthritis pain, depression, loneliness, etc. Unfortunately for the system, the response here involves a fire truck, first responder AND an ambulance, and I know that runs into a lot of money. But what can be done?

  4. Happy, how are we who aren't yet providers going to be able to make a difference? From my limited experience as a Basic Student so far, no one seems to respect the opinion of someone that hasn't actually ran a call yet. I agree that we don't know how things work “on the street” but even just with the scenarios that you have presented, I think a layperson would be very hard pressed to justify an ambulance transport of those patients, yet they seem to expect it… why can't the EMT or Medic on the rig that responds to those type of call tell the patient to “get lost”? why is liability such a major issue?

    ~Brad
    @EMTGoose

  5. given the level of discourse among our patients, the xanax refill guy or the asthma girl would then just say they have cp/sob and demand you take him/her to the hospital.

    what i’d love to see if what you’re calling for – for our bosses to have some backbone and back us up, and then we can tell those two abusers to go to walgreens and quit calling us. but we (from medics all the way up to ED docs) need to be very, very strong in refusing to help them refill their meds, so people will learn that it’s no use for them to call 911 for refills. if there is anyone in that hierarchy who so much as sympathizes with a med refill, then it’s as if there’s a weakness for these pts to exploit, and our plan will not work.

    is it true DPH used to have bus tokens and told homeless guys to fuck off and wait for muni?

  6. I live in an apt complex with older residents, all of whom are SUPPOSED to be living independently with only minimal health problems. Too many of my neighbors call 911, and get full response, for light-headed feelings, arthritis pain, depression, loneliness, etc. Unfortunately for the system, the response here involves a fire truck, first responder AND an ambulance, and I know that runs into a lot of money. But what can be done?

  7. given the level of discourse among our patients, the xanax refill guy or the asthma girl would then just say they have cp/sob and demand you take him/her to the hospital.

    what i'd love to see if what you're calling for – for our bosses to have some backbone and back us up, and then we can tell those two abusers to go to walgreens and quit calling us. but we (from medics all the way up to ED docs) need to be very, very strong in refusing to help them refill their meds, so people will learn that it's no use for them to call 911 for refills. if there is anyone in that hierarchy who so much as sympathizes with a med refill, then it's as if there's a weakness for these pts to exploit, and our plan will not work.

    is it true DPH used to have bus tokens and told homeless guys to fuck off and wait for muni?

  8. I wok for a private service that provides primary911 service to 6 communities ( and back up several more) and we also have a van. They are called chair cars here and I did that for over 10 years before I got my EMT-B. The ambulances still take people to dialysis but we can free up resources for those who need it. We also have 1 large bus and 2 mini buses 160-odd vehicles in the fleet!

  9. I wok for a private service that provides primary911 service to 6 communities ( and back up several more) and we also have a van. They are called chair cars here and I did that for over 10 years before I got my EMT-B. The ambulances still take people to dialysis but we can free up resources for those who need it. We also have 1 large bus and 2 mini buses 160-odd vehicles in the fleet!

  10. I wok for a private service that provides primary911 service to 6 communities ( and back up several more) and we also have a van. They are called chair cars here and I did that for over 10 years before I got my EMT-B. The ambulances still take people to dialysis but we can free up resources for those who need it. We also have 1 large bus and 2 mini buses 160-odd vehicles in the fleet!

  11. I think that the biggest problem is that we see the system breaking down from the inside but feel powerless to change it. We need to have the power in the field to look at the patient and determine if they need emergency treatment or not. If we aren’t jumping in and immediately giving them oxygen, starting a line and thinking about the fastest way to the nearest facility then we should take a step back and think about what is best for the patient (*always patient first) and best for the system and community.

    For some conservative systems, this may mean we need to consult very carefully to get this kind of special transport diversion to a wheel chair van, taxi, or maybe even a follow-up from a home care nurse the next day. This is the answer to the current state of affairs, though.

    I wonder if anyone not riding in the back of an ambulance every day even sees it?

  12. I think that the biggest problem is that we see the system breaking down from the inside but feel powerless to change it. We need to have the power in the field to look at the patient and determine if they need emergency treatment or not. If we aren't jumping in and immediately giving them oxygen, starting a line and thinking about the fastest way to the nearest facility then we should take a step back and think about what is best for the patient (*always patient first) and best for the system and community.

    For some conservative systems, this may mean we need to consult very carefully to get this kind of special transport diversion to a wheel chair van, taxi, or maybe even a follow-up from a home care nurse the next day. This is the answer to the current state of affairs, though.

    I wonder if anyone not riding in the back of an ambulance every day even sees it?

  13. I think that the biggest problem is that we see the system breaking down from the inside but feel powerless to change it. We need to have the power in the field to look at the patient and determine if they need emergency treatment or not. If we aren't jumping in and immediately giving them oxygen, starting a line and thinking about the fastest way to the nearest facility then we should take a step back and think about what is best for the patient (*always patient first) and best for the system and community.

    For some conservative systems, this may mean we need to consult very carefully to get this kind of special transport diversion to a wheel chair van, taxi, or maybe even a follow-up from a home care nurse the next day. This is the answer to the current state of affairs, though.

    I wonder if anyone not riding in the back of an ambulance every day even sees it?

  14. We are at essence a public health agency. We’re educated to be able to discern disease process and render the correct course of treatment and by the same token educate our patients better about their disease and how they can seek the most appropriate treatment. Which is not always going to include an ALS transport/ALS bill they may not be able to afford, ER visit where they are left in triage or a hall bed and not talked to until discharge w/no change in status from admission barring an ER bill they may also not be able afford.
    I just went on a call three days ago for a 10 year old calloused growth on a person’s foot and by his admission it was no worse today, he just wanted it to be incised and sutured. I informed him we could not perform those procedures for him and that the ER would not either, they would assess it, and refer him to a foot specialist, given the non-emergent nature of the issue. He then informed me as we dug into this further that he had seen a foot specialist 6 years earlier and decided he didn’t want to get it done then. We discussed following up w/insurance and getting a new appt w/said specialist. This is one of the call that we’re all talking about here, it’s about education of our pts one at a time and I’m happy to do it, it’s what I’m paid to do, my job isn’t a singular focus, after all don’t we provide some education w/our refusals to ensure that they understand what they’re refusing and what could happen, let’s just expand the focus. I agree w/podmedic, it’s a patient centric job/we need to do what’s right for them not us, as soon as our ego becomes part of it it’s time to move on.

  15. We are at essence a public health agency. We're educated to be able to discern disease process and render the correct course of treatment and by the same token educate our patients better about their disease and how they can seek the most appropriate treatment. Which is not always going to include an ALS transport/ALS bill they may not be able to afford, ER visit where they are left in triage or a hall bed and not talked to until discharge w/no change in status from admission barring an ER bill they may also not be able afford.
    I just went on a call three days ago for a 10 year old calloused growth on a person's foot and by his admission it was no worse today, he just wanted it to be incised and sutured. I informed him we could not perform those procedures for him and that the ER would not either, they would assess it, and refer him to a foot specialist, given the non-emergent nature of the issue. He then informed me as we dug into this further that he had seen a foot specialist 6 years earlier and decided he didn't want to get it done then. We discussed following up w/insurance and getting a new appt w/said specialist. This is one of the call that we're all talking about here, it's about education of our pts one at a time and I'm happy to do it, it's what I'm paid to do, my job isn't a singular focus, after all don't we provide some education w/our refusals to ensure that they understand what they're refusing and what could happen, let's just expand the focus. I agree w/podmedic, it's a patient centric job/we need to do what's right for them not us, as soon as our ego becomes part of it it's time to move on.

  16. We are at essence a public health agency. We're educated to be able to discern disease process and render the correct course of treatment and by the same token educate our patients better about their disease and how they can seek the most appropriate treatment. Which is not always going to include an ALS transport/ALS bill they may not be able to afford, ER visit where they are left in triage or a hall bed and not talked to until discharge w/no change in status from admission barring an ER bill they may also not be able afford.
    I just went on a call three days ago for a 10 year old calloused growth on a person's foot and by his admission it was no worse today, he just wanted it to be incised and sutured. I informed him we could not perform those procedures for him and that the ER would not either, they would assess it, and refer him to a foot specialist, given the non-emergent nature of the issue. He then informed me as we dug into this further that he had seen a foot specialist 6 years earlier and decided he didn't want to get it done then. We discussed following up w/insurance and getting a new appt w/said specialist. This is one of the call that we're all talking about here, it's about education of our pts one at a time and I'm happy to do it, it's what I'm paid to do, my job isn't a singular focus, after all don't we provide some education w/our refusals to ensure that they understand what they're refusing and what could happen, let's just expand the focus. I agree w/podmedic, it's a patient centric job/we need to do what's right for them not us, as soon as our ego becomes part of it it's time to move on.

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