You Make the Call – MotorDoc – What Happened

I was hoping the word kidnapping would come into play on THIS scenario from Friday.

 

The Doc doesn't want a trip to the trauma center, even though he meets the criteria that he helped create for us sad, lonely medics who can't use our own judgment.

He was separated from the bike after hitting the side of a truck somewhere a bit less than 30mph, or so he says, and there is no gray area on this one for my system.

He meets trauma criteria wether or not I think he should go.  Such is the state of EMS in my system at the present time.  Even though he presents alert and oriented, he himself would be the first one down our throats about how the clavicle is a distracting injury and hitting his flank could also have injured his pelvis and abdomen.

We could go on for years about wether he is or isn't injured, but there is no need.  There is also only one way I can transport him to another facility outside our protocols.

Direct Medical Control.

You see, regardless of where your patient WANTS to go, it is your responsibility to make every effort to take them where they NEED to go.  If Erma having the CVA demands a hospital without a scanner, call ahead and have them divert you.  Taking her to the wrong place based on her request is worse than "kidnapping" I'd argue it's downright neglectful.

Imagine we take Mr MotorDoc to Saint Farthest, per his request, documenting in quotations everything he says, heck, even get a photocopy of his ID for the report.  All those items will look really good blown up at the trial after his injuries turn out to be more than you thought and he cites you violated clear cut trauma protocols.

This is not a matter of Kaiser vs a Blue Shield participating Hospital, this is a matter of getting a patient to difinitive care.

 

So, back to MotorDoc.  A simple phone call to the attending Medical Control Physician explaining our situation got the intended response.  MotorDoc had to explain his injuries and his reasoning to the attending to get permission to deviate from protocol and be seen at Saint Farthest.  At that point it is the Physician's responsibility should the injuries turn out to be more than we thought.

And the best part of the story?  The attending wanted him to come into the trauma center and from what we could tell did everything we had already done to convince him to do so.

Destination protocols are a necessary tool to keep track of which hospitals in your area can be the best resource to your patients.  Keep in mind they may not know their requested hospital can not help them and it is your responsibility to make sure they get the care they need.

 

If you said kick the decision upstairs, you made my call.

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19 thoughts on “You Make the Call – MotorDoc – What Happened”

  1. Direct Medical Control was made for situations like this… However, He’s A+OX4. He’s not intoxicated. He’s reasonable and appropriate. He’s neurologically intact. What if he tells you and his ER doc buddy to pound sand and seeks POV transport to Saint Farthest? That would be a more compelling conundrum.

    1. If he RMA’s and seeks POV to St. Farthest, then it’s in documentation that he chose to ignore the advice of both the DMC doc and the medics on the scene. Just got to make sure you CYA and make it grossly clear that he’s doing so against protocols in this case. Perhaps saying “And the patient is requesting to go to St. Farthest, in denial of the DMC’s advice, the treating Medic’s advice, and in violation of standing orders, as written by his office. Patient has been advised of his rights as he signs the RMA, and is witnessed” should cover a lot of sins.

    2. He’s alert and oriented, sure. He denies being under the influence of anything, indeed. He’s unreasonable and inappropriate however. His injury is consistent with possible other injuries and is classified, in my mind, as distracting as well as being embarrassed that he crashed his motorcycle.
      If he wants to go POV to St Farthest, then I’ll let him, AFTER he talks to my MCEP and after I call ahead to both St Farthest and our control to have another ambulance waiting there when they can’t handle his injuries.

      This falls under the “any reasonable person” reasoning we are threatened with so often.

      1. In my system, protocol also lets the ultimate transport decision lie with the alert/oriented pt. That being said, like you pointed out, it does not prevent me from trying all avenues to persuade him into going with me to the appropriate facility. A call to to medical control is definitely in order to help, as well as me letting him hear St. Farthest tell me on the radio that they’re not equipped for such a patient.

        Had the situation happen to me twice in my career (neither patient was a doctor, just a stubborn person who didn’t like ER staff), and ended up batting .500 . One time, the radio transmission did the trick. The other time, the pt. (STEMI) said he’d “rather die than go to that place again” and signed AMA to go to his choice POV, even after hearing the radio traffic. My Captain did what Justin mentioned, and called the hospital to let them know what was headed their way.

  2. Direct Medical Control was made for situations like this… However, He’s A+OX4. He’s not intoxicated. He’s reasonable and appropriate. He’s neurologically intact. What if he tells you and his ER doc buddy to pound sand and seeks POV transport to Saint Farthest? That would be a more compelling conundrum.

    1. If he RMA’s and seeks POV to St. Farthest, then it’s in documentation that he chose to ignore the advice of both the DMC doc and the medics on the scene. Just got to make sure you CYA and make it grossly clear that he’s doing so against protocols in this case. Perhaps saying “And the patient is requesting to go to St. Farthest, in denial of the DMC’s advice, the treating Medic’s advice, and in violation of standing orders, as written by his office. Patient has been advised of his rights as he signs the RMA, and is witnessed” should cover a lot of sins.

    2. If he RMA’s and seeks POV to St. Farthest, then it’s in documentation that he chose to ignore the advice of both the DMC doc and the medics on the scene. Just got to make sure you CYA and make it grossly clear that he’s doing so against protocols in this case. Perhaps saying “And the patient is requesting to go to St. Farthest, in denial of the DMC’s advice, the treating Medic’s advice, and in violation of standing orders, as written by his office. Patient has been advised of his rights as he signs the RMA, and is witnessed” should cover a lot of sins.

    3. He’s alert and oriented, sure. He denies being under the influence of anything, indeed. He’s unreasonable and inappropriate however. His injury is consistent with possible other injuries and is classified, in my mind, as distracting as well as being embarrassed that he crashed his motorcycle.
      If he wants to go POV to St Farthest, then I’ll let him, AFTER he talks to my MCEP and after I call ahead to both St Farthest and our control to have another ambulance waiting there when they can’t handle his injuries.

      This falls under the “any reasonable person” reasoning we are threatened with so often.

    4. He’s alert and oriented, sure. He denies being under the influence of anything, indeed. He’s unreasonable and inappropriate however. His injury is consistent with possible other injuries and is classified, in my mind, as distracting as well as being embarrassed that he crashed his motorcycle.
      If he wants to go POV to St Farthest, then I’ll let him, AFTER he talks to my MCEP and after I call ahead to both St Farthest and our control to have another ambulance waiting there when they can’t handle his injuries.

      This falls under the “any reasonable person” reasoning we are threatened with so often.

      1. In my system, protocol also lets the ultimate transport decision lie with the alert/oriented pt. That being said, like you pointed out, it does not prevent me from trying all avenues to persuade him into going with me to the appropriate facility. A call to to medical control is definitely in order to help, as well as me letting him hear St. Farthest tell me on the radio that they’re not equipped for such a patient.

        Had the situation happen to me twice in my career (neither patient was a doctor, just a stubborn person who didn’t like ER staff), and ended up batting .500 . One time, the radio transmission did the trick. The other time, the pt. (STEMI) said he’d “rather die than go to that place again” and signed AMA to go to his choice POV, even after hearing the radio traffic. My Captain did what Justin mentioned, and called the hospital to let them know what was headed their way.

  3. Direct Medical Control was made for situations like this… However, He’s A+OX4. He’s not intoxicated. He’s reasonable and appropriate. He’s neurologically intact. What if he tells you and his ER doc buddy to pound sand and seeks POV transport to Saint Farthest? That would be a more compelling conundrum.

  4. Here’s what we work with in Alabama:

    From the Alabama Department of Public Health, Office of EMS & Trauma, Patient Care Protocols, EMT-Paramedic, Edition 5, June 2010

    “An adult patient who is conscious and alert has the right to select a hospital to which he/she
    is to be transported, and neither the EMS service nor OLMD has the right to override that
    decision. If the hospital is on diversion status and the patient still demands to be taken to that
    hospital, the EMS service must honor this request and OLMD cannot override this decision.
    If, in your judgment, transport to the patient’s chosen hospital will cause loss of life or limb,
    and you cannot convince the patient to allow you to take him/her to a more appropriate
    hospital, contact your OLMD (On-Line Medical Direction) or service medical director and ask him/her to speak to the
    patient. If the patient still demands to go to the inappropriate hospital, you must honor this
    request.”

    No real conundrum here. We gotta go where the patient wants. Yes, medical direction may be contacted. No, neither the physician, nor our trauma system protocols can legally override the patient.

    I’ve taken several patients to what I considered the “wrong” hospital, and watched them go on and die because of it. In each case, I followed the protocol.

    Felt wrong then. Still does.

  5. Here’s what we work with in Alabama:

    From the Alabama Department of Public Health, Office of EMS & Trauma, Patient Care Protocols, EMT-Paramedic, Edition 5, June 2010

    “An adult patient who is conscious and alert has the right to select a hospital to which he/she
    is to be transported, and neither the EMS service nor OLMD has the right to override that
    decision. If the hospital is on diversion status and the patient still demands to be taken to that
    hospital, the EMS service must honor this request and OLMD cannot override this decision.
    If, in your judgment, transport to the patient’s chosen hospital will cause loss of life or limb,
    and you cannot convince the patient to allow you to take him/her to a more appropriate
    hospital, contact your OLMD (On-Line Medical Direction) or service medical director and ask him/her to speak to the
    patient. If the patient still demands to go to the inappropriate hospital, you must honor this
    request.”

    No real conundrum here. We gotta go where the patient wants. Yes, medical direction may be contacted. No, neither the physician, nor our trauma system protocols can legally override the patient.

    I’ve taken several patients to what I considered the “wrong” hospital, and watched them go on and die because of it. In each case, I followed the protocol.

    Felt wrong then. Still does.

  6. My favorite medical control story just happened:

    0345 the other night. 30 y/o male at fleabag motel claims to have had a seizure related to a brain aneurysm, is agitated and uncooperative-and smells like a bar. Ambulance shows up and it is the same crew that had transported him to the closest hospital (1/4 mile away) from a bar in a neighboring city at 0235. He left AMA, took a cab back to the motel and called 911 again. He walks to the ambulance with our assistance then demands to be taken to our St Farthest. Ambulance medic called OLMC-which is the same hospital he left AMA-and they state he is to be returned there or the ambulance can refuse transport. WIN. The guy signs the refusal and says he will take a cab to Farthest. Then, as we’re leaving, we watch as this guy who we had to help walk to the ambulance SPRINTS back to his room. I’ll remember that when we see him again.

  7. My favorite medical control story just happened:

    0345 the other night. 30 y/o male at fleabag motel claims to have had a seizure related to a brain aneurysm, is agitated and uncooperative-and smells like a bar. Ambulance shows up and it is the same crew that had transported him to the closest hospital (1/4 mile away) from a bar in a neighboring city at 0235. He left AMA, took a cab back to the motel and called 911 again. He walks to the ambulance with our assistance then demands to be taken to our St Farthest. Ambulance medic called OLMC-which is the same hospital he left AMA-and they state he is to be returned there or the ambulance can refuse transport. WIN. The guy signs the refusal and says he will take a cab to Farthest. Then, as we’re leaving, we watch as this guy who we had to help walk to the ambulance SPRINTS back to his room. I’ll remember that when we see him again.

  8. There does need to be some sort of limits on how far we transport beyond the closest appropriate hospital. I the patient requests a hospital that is an hour farther than the closest appropriate hospital, there is a problem. This is rare, but it does happen.

    I had a cardiologist with obvious rule in for STEMI refuse transport. I had him talk with medical command. The cardiologist was alert and oriented and able to explain the possible complications of refusal better than a non-cardiologist.

    What authority do I have to kidnap this doctor?

    As long as I am just kidnapping the doctor to protect myself from potential liability, why shouldn’t I?

    How far may I go in kicking, biting, spitting, whining, et cetera to coerce the doctor to go?

    TASER? GSW? High-dose Ativan?

    Where do we get to say that we are above the law?

  9. There does need to be some sort of limits on how far we transport beyond the closest appropriate hospital. I the patient requests a hospital that is an hour farther than the closest appropriate hospital, there is a problem. This is rare, but it does happen.

    I had a cardiologist with obvious rule in for STEMI refuse transport. I had him talk with medical command. The cardiologist was alert and oriented and able to explain the possible complications of refusal better than a non-cardiologist.

    What authority do I have to kidnap this doctor?

    As long as I am just kidnapping the doctor to protect myself from potential liability, why shouldn’t I?

    How far may I go in kicking, biting, spitting, whining, et cetera to coerce the doctor to go?

    TASER? GSW? High-dose Ativan?

    Where do we get to say that we are above the law?

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