Which liability?

Detroit by Patricia Drury on flickrI've discussed this here many, many, many times before.

 

When you trade actual liability for perceived liability, it kills people and gets bad press in the process.

 

The perceived liability that a patient will sue you for not taking them in for a clearly non-medical complaint pales in comparrison with the ACTUAL liability of having too few ambulances to handle actual emergencies.

 

Whether your solution to this mess is privitization (Yeah, try to turn a profit there.  Or here for that matter) or not, the solution is clear.  It is time EMS stands up and says "NO."

I am a trained medical professional armed with state of the art equipment to assess your chief complaint and I have found that you do not need an ambulance so I will arrange alternative transport to the physician.

No more transport them all and let the MDs sort it out.  It never worked, it will never work.

 

Detroit EMS, as with most other systems, including my own, have chosen to hide behind a false definition of liability, instead rolling the dice and hoping nothing will happen.

And we all know what happens when you work in EMS and hope nothing will happen.

A senior staffer will likely step down, replaced by another senior staffer who will enact the same policies and wonder if something new will happen.

See also: Insanity

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24 thoughts on “Which liability?”

  1. My problem with this is that if EMS has the right to refuse transport, we can never be sure that the slight abdominal pain is not actually a massive MI. As seen in the DC case. We as EMS providers have no ability to truly differentiate completely stable patients and patients that will go unstable in a moment. And if we deny transport to such a patient, WE ARE LIABLE. This is the reason that I always transport if the patient wants to go to the hospital.

    1. PremedEMT, and you’d be right to transport the abdominal pain, because that is one of the many complaints that we indeed can’t rule out an MI. Or can we? What if I told you that with current technology I COULD rule out an MI pre-hospital, given $80 and 15 minutes? That’s another debate entirely.
      I’m more focused on the sore wrists, tooth aches, recurring back pain from 25 years ago, Doctor’s Office closing time transports (this is just from yesterday) can be redirected.
      Thanks for reading

      1. Leaving the cardiac enzymes question aside (i have one thing to say,Heart Specific Fatty acid Binding protein (FABP) detection , it is the future: fast, easy, and can be manufactured like your glucometer with results in seconds)

        I am starting to see your point and can agree with you (as long as it is well regulated).

        Thanks for the response

    2. 1. I don’t know if I would characterize the DC case as “slight abdominal pain.”

      2. It was a pulmonary embolism, not an MI. http://firelawblog.com/files/2011/02/thomasdecision.jsp_.pdf

      3. Deciding to transport any case based only on a chief complaint is foolish, dangerous, and well, stupid. That decision needs to be based on a complete assessment using point of care testing as appropriate. Not all sore throats should be left at home. Nor should all abdominal pains be left at home.

      The best defense against liability is completing a thorough history and physical, not transporting everyone blindly.

      The best defense against liability is evidence based medicine, not tradition.

      -Joe Paczkowski
      The EMT-Medical Student

  2. My problem with this is that if EMS has the right to refuse transport, we can never be sure that the slight abdominal pain is not actually a massive MI. As seen in the DC case. We as EMS providers have no ability to truly differentiate completely stable patients and patients that will go unstable in a moment. And if we deny transport to such a patient, WE ARE LIABLE. This is the reason that I always transport if the patient wants to go to the hospital.

    1. PremedEMT, and you’d be right to transport the abdominal pain, because that is one of the many complaints that we indeed can’t rule out an MI. Or can we? What if I told you that with current technology I COULD rule out an MI pre-hospital, given $80 and 15 minutes? That’s another debate entirely.
      I’m more focused on the sore wrists, tooth aches, recurring back pain from 25 years ago, Doctor’s Office closing time transports (this is just from yesterday) can be redirected.
      Thanks for reading

      1. Leaving the cardiac enzymes question aside (i have one thing to say,Heart Specific Fatty acid Binding protein (FABP) detection , it is the future: fast, easy, and can be manufactured like your glucometer with results in seconds)

        I am starting to see your point and can agree with you (as long as it is well regulated).

        Thanks for the response

    2. 1. I don’t know if I would characterize the DC case as “slight abdominal pain.”

      2. It was a pulmonary embolism, not an MI. http://firelawblog.com/files/2011/02/thomasdecision.jsp_.pdf

      3. Deciding to transport any case based only on a chief complaint is foolish, dangerous, and well, stupid. That decision needs to be based on a complete assessment using point of care testing as appropriate. Not all sore throats should be left at home. Nor should all abdominal pains be left at home.

      The best defense against liability is completing a thorough history and physical, not transporting everyone blindly.

      The best defense against liability is evidence based medicine, not tradition.

      -Joe Paczkowski
      The EMT-Medical Student

  3. I agree totally. I’ve worked for a ‘for profit’ company. I have refused to transport a few cut fingers (they called an ambulance because they were told welfare or similar would cover the cost), but was told flat out that the company’s policy was NOT to discourage transport for anyone. I have also seen the area depleted of ambulances because 5 of the 8 ambulances are out on non-urgent, mostly psych, 200 mile each way transports. This is because, as we all know, that’s where the money is. A large municipal fire run ambulance service with a strong medical director has started empowering its medics to make transport decisions but putting certain protocols in place. Long gone should be the day of the taxi with the lights and siren.

  4. I agree totally. I’ve worked for a ‘for profit’ company. I have refused to transport a few cut fingers (they called an ambulance because they were told welfare or similar would cover the cost), but was told flat out that the company’s policy was NOT to discourage transport for anyone. I have also seen the area depleted of ambulances because 5 of the 8 ambulances are out on non-urgent, mostly psych, 200 mile each way transports. This is because, as we all know, that’s where the money is. A large municipal fire run ambulance service with a strong medical director has started empowering its medics to make transport decisions but putting certain protocols in place. Long gone should be the day of the taxi with the lights and siren.

  5. There is a very large difference in initiating a different form of transport for a finger lac. vs. undiagnosed abdominal pain. The problem stems from liability, EMS education and medical control. We have come a long way since Johnny and Roy, but not that far. The system is in a hole that is exponentially deepening. Higher population=higher call volume and as we know, the typical 911 call is not emergent and the financial support of EMS is obviously not keeping up with the population. Alternate disposition…Is it the answer to ALL of the problems?? I don’t know, but I do know the system is broken and it’s not getting any better when I transport someone to an ED because they need there medication filled.

    1. I understand the frustration with what we perceive as unnecessary transports – I really do. But please consider these points.

      1. I can find no liability for a system that runs out of ambulances. There is this thing called the “public duty doctrine” that says that the government has no inherent duty to rescue anybody who calls the police, fire, EMS, etc. There are exceptions, but if all the cops are busy and somebody gets robbed or killed, or if the fire department is busy and has a long response and the hourse burns down, the town is not liable.

      2. We may be health professionals with a bunch of training, but I know very few (zero) paramedics who have one minute of training in hospital destination triage or decision-making. It’s not part of our curriculum, nor our licensure testing, nor our standing orders. Do I think it should be (all of these)? Absolutely! But it is not. Until it is, the risk is ours…..

      3. Getting people to someplace besides the ED is a problem. Lots of our patients are poor, uninsured, etc. Unfortunately, the ONLY place that MUST see them is the hospital ED. EMTALA doesn’t apply to the urgent care clinic, the doc in the box, etc. In America we have socialized medicine – that includes EMS and the ED, but nobody else. So until something changes (everybody has insurance, or EMTALA extends its reach), the ED is the only alternative.

      Not a pretty picture – but it is a SYSTEM problem and should be solved at a system level – not by individual medics free-lancing without the requisite training or authority.

      1. Skip-
        You nailed it on the head right here: “There is this thing called the “public duty doctrine” that says that the government has no inherent duty to rescue anybody who calls the police, fire, EMS, etc.” I apply that definition to code 2 sick eval calls and lacerated fingers. After all, if we’re not required to respond, why are we required to transport?

        My system has an annual refresher on our destination hospital policies, directing us to take MIs to one place, PEDS to another, CVAs to another and microsurgery to yet another. I’m asked by triage nurses the severity of injury and moving patients from my cot to the waiting room based only on my judgment. we’re already doing their job, why not let us do it BEFORE we waste the transport unit on a non transport necessary call?
        If I can be trusted not to activate the trauma team on the lacerated finger, perhaps I can be trusted to direct them elsewhere.

        We all know health care is expensive because we waste the most expensive methods of evaluation (EMS and the ED) on every single case. The system will not change until it is no longer a for profit model. As I’ve said before, there is no profit in a refusal, no matter how appropriate for the patient. we seem to be patient advocates right up until we can have the most impact: non-transport.
        Thanks for reading and commenting. I want that definition from earlier on a T-shirt!

  6. There is a very large difference in initiating a different form of transport for a finger lac. vs. undiagnosed abdominal pain. The problem stems from liability, EMS education and medical control. We have come a long way since Johnny and Roy, but not that far. The system is in a hole that is exponentially deepening. Higher population=higher call volume and as we know, the typical 911 call is not emergent and the financial support of EMS is obviously not keeping up with the population. Alternate disposition…Is it the answer to ALL of the problems?? I don’t know, but I do know the system is broken and it’s not getting any better when I transport someone to an ED because they need there medication filled.

    1. I understand the frustration with what we perceive as unnecessary transports – I really do. But please consider these points.

      1. I can find no liability for a system that runs out of ambulances. There is this thing called the “public duty doctrine” that says that the government has no inherent duty to rescue anybody who calls the police, fire, EMS, etc. There are exceptions, but if all the cops are busy and somebody gets robbed or killed, or if the fire department is busy and has a long response and the hourse burns down, the town is not liable.

      2. We may be health professionals with a bunch of training, but I know very few (zero) paramedics who have one minute of training in hospital destination triage or decision-making. It’s not part of our curriculum, nor our licensure testing, nor our standing orders. Do I think it should be (all of these)? Absolutely! But it is not. Until it is, the risk is ours…..

      3. Getting people to someplace besides the ED is a problem. Lots of our patients are poor, uninsured, etc. Unfortunately, the ONLY place that MUST see them is the hospital ED. EMTALA doesn’t apply to the urgent care clinic, the doc in the box, etc. In America we have socialized medicine – that includes EMS and the ED, but nobody else. So until something changes (everybody has insurance, or EMTALA extends its reach), the ED is the only alternative.

      Not a pretty picture – but it is a SYSTEM problem and should be solved at a system level – not by individual medics free-lancing without the requisite training or authority.

      1. Skip-
        You nailed it on the head right here: “There is this thing called the “public duty doctrine” that says that the government has no inherent duty to rescue anybody who calls the police, fire, EMS, etc.” I apply that definition to code 2 sick eval calls and lacerated fingers. After all, if we’re not required to respond, why are we required to transport?

        My system has an annual refresher on our destination hospital policies, directing us to take MIs to one place, PEDS to another, CVAs to another and microsurgery to yet another. I’m asked by triage nurses the severity of injury and moving patients from my cot to the waiting room based only on my judgment. we’re already doing their job, why not let us do it BEFORE we waste the transport unit on a non transport necessary call?
        If I can be trusted not to activate the trauma team on the lacerated finger, perhaps I can be trusted to direct them elsewhere.

        We all know health care is expensive because we waste the most expensive methods of evaluation (EMS and the ED) on every single case. The system will not change until it is no longer a for profit model. As I’ve said before, there is no profit in a refusal, no matter how appropriate for the patient. we seem to be patient advocates right up until we can have the most impact: non-transport.
        Thanks for reading and commenting. I want that definition from earlier on a T-shirt!

    1. Not “A” long day but I’ve seen the writing on the wall for awhile, but now the writing is in 12 foot tall letters in 3D and we as EMS have yet to alter our system a fraction aside from random changes to CPR, CPAP and STEMI. we add so many things to our rigs, but never stop and think what they’re doing when they get there. 100% of our system is designed around 5% (not intended to be a factual statement) of our patients. The rest of them are using resources they don’t need.
      THAT is where the next innovation needs to be.
      Thanks for reading box 8520…Is that 19s or 40s 1st due?

    1. Not “A” long day but I’ve seen the writing on the wall for awhile, but now the writing is in 12 foot tall letters in 3D and we as EMS have yet to alter our system a fraction aside from random changes to CPR, CPAP and STEMI. we add so many things to our rigs, but never stop and think what they’re doing when they get there. 100% of our system is designed around 5% (not intended to be a factual statement) of our patients. The rest of them are using resources they don’t need.
      THAT is where the next innovation needs to be.
      Thanks for reading box 8520…Is that 19s or 40s 1st due?

  7. privet services will always demand 100% transports, it’s all about money. they can go after these people and some of them are very ruthless at doing it. don’t let them fool you it’s all about liability. people have the god given right to refuse medical care.

  8. My feeling is that in order to ever get to this type of system, the people in charge will need to learn to accept the option of a reasonably small chance of adverse outcomes, rather than “no” chance (which of course just means as little chance as is achievable). Because if we ever take steps that amount to saying, “you COULD have Something Bad, but it’s very unlikely, so we’re not going to throw the kitchen sink at you,” then eventually somebody is going to be that adverse statistic, and we have to decide ahead of time that they’re NOT an aberration or an error, but an inevitable part of the system. When you lay it out like this, it doesn’t sound very appetizing, but in reality neither is throwing infinite dollars and resources at vanishing possibilities of harm (and hence liability). That game’s been played for a long time and the direction it’s taking us is bad for everyone. The line can and should be a conservative one, but it needs to be drawn somewhere.

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