Patient kidnapping – The cowtipping of EMS

Kidnapping!

I’ve been sitting on this post for months and recent discussions on the facebook and around the interwebs are leading me to revisit it.

 

In an old You Make the Call we discussed when to take people to a  certain medical facility versus another and, sure enough, the topic of kidnapping came up.

It was reinforced in a (not so) recent story out of Florida about a man who claims to have been transported against his will.

 

Much in the same way Country kids sell the legend of cow tipping to City kids, I believe kidnapping of patients is an urban legend perpetuated by EMS managers and Chiefs alike to keep us from making waves and doing the right thing.  They need transport dollars to survive and taking people to their hospital of choice is an easier bill than not.

Are you confused with the definition, both of the word and the action?

 

kidnapping n. the taking of a person against his/her will (or from the control of a parent or guardian) from one place to another under circumstances in which the person so taken does not have freedom of movement, will, or decision through violence, force, threat or intimidation. Although it is not necessary that the purpose be criminal (since all kidnapping is a criminal felony) the capture usually involves some related criminal act such as holding the person for ransom, sexual and/or sadistic abuse, or rape. It includes taking due to irresistible impulse and a parent taking and hiding a child in violation of court order. An included crime is false imprisonment. Any harm to the victim coupled with kidnapping can raise the degree of felony for the injury and can result in a capital (death penalty) offense in some states, even though the victim survives. Originally it meant the stealing of children, since “kid” is child in Scandinavian languages, but now applies to adults as well.

Gerald N. Hill and Kathleen T. Hill.

Hmmm…

Taking someone to a hospital where they will receive medical care is not kidnapping as far as I can tell.  I’ve been looking at many different definitions of kidnapping over the week and keep coming back to the same definitions at heart.

If you do it for the right reasons, how can it be the wrong thing to do?

If you are doing it to get back to dinner, get off duty on time, or because your manager tells you to, THEN we have an issue since your position of authority could be interpreted as intimidation, but taking someone having an MI to a proper facility instead of local band aid ER is not kidnapping as far as I can find.

This discussion started when we discussed a patient who did not want to be taken to the appropriate medical facility for his presentation.  The discussion that followed revolved around him being “alert and oriented” “not intoxicated” and “I’m not going to kidnap him.”

In that situation YOU AREN’T!

You may do some research and find a term called “simple kidnapping” which appears to cover a slew of false imprisonments, holding without permission, and similar crimes, but in no definition do I find an example of a kidnapping being taking someone to the hospital.

Keep in mind your jurisdiction may have their own definition and you need to be familiar with it, but let me extend this one hypothetical step further.  If a person claims they need a transport and take me against my will, since I don’t think they need to go, is THAT kidnapping?  I’m being forced to go somewhere by fraud and could suffer harm as a result.

That more closely fits the definition of kidnap than taking a person to an appropriate medical facility, conscious & alert or not.

 

We are told not to disobey the patient and do what they say, take them where they want, and 95% of the time that works out just fine.  Your stomach hurts?  Sure we can goto St Farthest.  Your leg itches again? Kaiser patient, not a problem.  Trauma patient wants to goto St Farthest?  Aren’t we supposed to be patient advocates and do everything we can for them?

Isn’t EMS supposed to be patient centric?  So why aren’t we teaching EMTs and Paramedics what the definition of kidnap really is?  Probably the same reason we avoid teaching them what liability really means.

There are a lot of problems that will come bubbling to the surface if we started acting in our patients’ best interests and none of them are ours OR theirs.

A common practice in my jurisdiction is the art of hospital shopping.  A person will identify as a member of a hospital they rarely attend because they believe the doctors there to be superior, or that the nurses are prettier, or the other place “kicked me out” but in actuality they are simply trying to get someplace new, or clean, or where lunch is served at 1 and it’s 12:45.

In the pilot episode of Beyond the Lights & Sirens, I had a conversation with a regular named Val.  She presented with chest pain, 10/10, radiating, with history, a mere 10 blocks from an appropriate facility.  Her requested facility, 2 hospitals and 25 minutes away was on saturation divert, or no longer accepting patients by ambulance.  I transported her, per chest pain protocol, to a hospital that was not her requested facility.  No kidnapping charges were filed.

Many of you would argue I kidnapped her.  I moved her from one place to another without her consent using intimidation (My position of authority).  But looking at the situation unfold, I did not kidnap her, but get her to the appropriate facility for her chief complaint, as defined by my Medical Director, County EMSA, State EMSA, Chiefs and Captains.

Don’t default to the stories the Anchors tell you about kidnapping charges being brought against a long lost co-worker for taking Erma to the wrong hospital.  That case likely had a different, more shady reason for leading to termination, not kidnapping.

Perhaps we should spend less time worrying about vague definitions that don’t apply and spend more time in the airway lab?

 

And I hate that I have to remind you of all this, but these words are my opinion and are not those of my employer, a lawyer, an expert, my daughter, the crossing guard or the guy at Sears who stocks the vacuum bags.  Before you act on these words, consult with your local system administrators for the rules and laws applicable in your area.

 

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26 thoughts on “Patient kidnapping – The cowtipping of EMS”

  1. But Justin,

    Take a look at what TMIACITW had over here: http://www.facebook.com/pages/The-Most-Interesting-Ambulance-Crew-in-the-World/123822834370598?ref=ts scroll down and look at the nursing home refusal debate. I can see no difference between what you suggest and how kidnapping is defined in the eyes of the law. Psych’s, drunks, altered mental status, etc., aren’t kiddnapping. Bring in Alert and Oriented, and that’s a whole ‘nother can of worms.

    Also, it depends on how your state defines kidnapping. Sure, a dictionary is a nice thing, but the real definition you want is in your state’s law books.

  2. I agree that taking someone to the appropriate facility is not kidnapping by itself.  However, patient hospital selection can also overlap with outright AMA refusals.  One example is the patient who says, “Either you take me to St. Farthest, or I’m not going anywhere!”, or the more common, “If you’re taking me to Poor Reputation Hospital, I’m getting off this gurney!”  What do you do if they really try to get off the gurney?  What happens if when you arrive at the hospital, the patient shouts that you lied to them and they won’t get OUT of the ambulance?

    When the patient links their hospital choice to a possible AMA refusal is where the spectre of “false imprisonment” raises its ugly head.

  3. I think there’s a varying number of issues here, and if Glenn Beck has his chalk board, I have my lists.

    1.  “Kidnapping” is often lay speak for any variety of crimes against persons involving detention and movement.

    California Penal Code 236: False imprisonment is the unlawful violation of the personal
    liberty of another.

    Additionally, per a lawyer’s website (I’m not going to go pull up the case law, but the case used to define this is listed as a reference), ”
    1.1. Restrained, confined, or detained

    Courts have held that “any exercise of force, express or implied, by
    which the other person is deprived of his liberty or is compelled to
    remain where he does not wish to remain, or to go where he does not wish
    to go, is an imprisonment.”9

    …and…

    “In order to convict you of misdemeanor false imprisonment, the prosecutor must prove the following facts (otherwise known as “elements” of the crime):

    that you intentionally restrained, confined, or detained another person, compelling him/her to stay or go somewhere, and that the other person did not consent.5″

    Source: http://www.shouselaw.com/false_imprisonment.html

    So, if the patient had capacity and a paramedic (given the recent “ambulance driver” blog discussions, I’m saying screw it, everyone is now a paramedic) transports that patient to a facility despite their objections and refuses them the ability to refuse care and get out, they have now deprived a person of their personal liberty and, based on a strict reading of California PC 236 have committed misdemeanor  false imprisonment. Your medical director, Local [county] EMS Agency, the California EMS Authority, chiefs, captains, and anyone else short of the state legislature carving out an exception (in which case you’re no longer breaking the law anymore than ambulances running with red lights is running a red light under the vehicle code) does not change the fact that you’re committing a public offense (i.e. crime). 

    So false imprisonment isn’t kidnapping, but it’s close enough that I’m not going to put paramedics through a ringer when it’s called kidnapping.

    2. District attorneys are elected (at least in California) to represent the people. Even if a person has committed a public offense based off of a strict reading of the penal code, it still requires the district attorney to file charges in the name of the People of the State of California. Somehow I don’t see that as happening unless it’s some sort of gross and stupid violation, not the standard, “patient needs [specialty center], patient goes to [specialty center], patient’s hospital choice be damned.

    1. All great points Joe, ansd it occurs to me we have more people involved in the “ambulance driver” definition discussion than these anymore.
      Depriving of someone of their personal liberty happens on most of our calls.  Patients without a need for transport will demand it and 2 of my paramedics (universal term) will be forced to go with that person to a place they did not want to go.  Duty to Act, it’s their job…I get it, but that definition more closely fits than taking someone who needs to go in.

      I’m not talking about Erma and her A-fib, or Johnny Ampersand and his chronically high BGL, but the conditions that will worsen if not evaluated by the proper specialties.
      The cases are very few and far between.  It seems the recent furvor over liberty has some Paramedics thinking that any person “who is A&Ox4″ can sign a form and go away.  We’ve all had patients who answer all the questions properly and still do not understand the severity of their condition.  If they refuse to accept the impression of the medic, how is their decision informed?
      “I’m fine” after the 5 minute seizure with unsteady gait, but “A&Ox4″ is a common one we see in my neck of the woods.
      Perhaps a seminar on what an informed patient refusal actually needs to include would be beneficial?

      Thanks for reading!
      HM

      1. The sad part is that this conversation is infinitely more important than discussing the word choice of the general public.

         ..and I get that we’re talking about patients who truly needs a specialty center. The patients who meet trauma criteria or who have a confirmed STEMI and the like. The problem is that patients have the right to make decisions, including bad decisions. Our job is to make sure they have adequate and appropriate information to make that decision, and in the vast majority of cases patients will bend to a higher medical authority than they are. However, as long as the patient knows what the paramedic’s impression and treatment plan is, and the consequences of not following it (including transport decision), how is that patient not informed? Bad choices are still choices.

        I agree that paramedics need a seminar, or really anything, on what makes both informed consent and an informed patient refusal. “A/Ox4″ isn’t significant enough for either capacity or an informed refusal, and a paramedic choosing to force treatment under implied consent (which is completely reasonable and the correct path when the patient legitimately does not have capacity) has to be similarly informed. The decision to release AMA -and- the decision to treat under implied consent both needs to be able to be justified by the attending paramedic.

  4. 3. [I wanted this in a different comment since it's a different issue]
    “Isn’t EMS supposed to be patient centric?  …

    There are a lot of problems that will come bubbling to the surface if
    we started acting in our patients’ best interests and none of them are
    ours OR theirs.”

    At what point are we becoming paternalistic in contrast to acting in the patient’s best interests? Patients have the right to make health care choices, including bad choices. Do we have the right to force a patient with chest pain to take ASA? Do we have the right to disregard a DNR because we disagree with “passive euthanasia” (the official ethical 50 cent term for DNRs)? Do we have the right to withhold pain medications to someone on a DNR even if it means you might shorten their life (thereby approaching active euthanasia), despite all good sense and most EMS DNR policies giving a green light to pain medication in that situation? Should the hospital ignore people who, for religious reasons, have a “no blood” card in their wallet?

    Where is the line where we should respect our patient’s wishes, for better or worse, or make those decisions for them? If you wouldn’t refuse to transport a patient to their physician’s office because you didn’t like the physician, then how can you likewise decide over their objections where they receive emergency medical care?

  5. Taking someone to a hospital where they will receive medical care is not kidnapping as far as I can tell.

    So, it is acceptable to deprive a patient of their rights, as long as we use the excuse that we were doing this for their own good – no matter how much of a lie that is?

    Using that excuse, which of us does not claim to know what is better for someone else?

    Why shouldn’t we just go abduct people from places where they would engage in activity we do not approve of?

    Why shouldn’t we abduct people and take them where we think they should be?

    Why not?

    .

    1. You’re describing the bulk of our patients.  As a Paramedic I have been educated and trained to recognize when someone needs evaluation by a physician and what conditions/events would impact their ability to make an informed decision regarding heir own care.  I am describing when a transport has been decided on and the destination is in question, mainly, but expanded my opinion outwards to all patients.

      Not the folks who are not patients, just patients.

      A person who refuses care and does not meet the definition of patient per my County can refuse any and all treatments they like at any time.

      A person with a medical complaint or who exhibits signs or symptoms of a medical or traumatic condition must be assessed and, if necessary, transported at my discretion based on the rule sof the system.  We are here for the good of the patient, as a noted blogger says, and sometimes taking them against their will when indicated IS in their best interest.  Leaving them to suffer because they are unable to make good decisions is bad medicine.

      Again, if they don’t have a medical or traumatic condition and are not experiencing an event that impairs their ability to make sound decisions, why am I even there?

      1. “A person who refuses care and does not meet the definition of patient
        per my County can refuse any and all treatments they like at any time.”

        Since there are two requirements (refuses care -and- does not meet the definition of a patient), does that mean a person who meets the definition of patient per SF LEMSA can’t refuse treatment and transport?

        The problem is that there’s a third option, the patient with a medical complaint or signs and symptoms of a medical or traumatic condition who has capacity, yet disagrees with your treatment plan or the treatment plan of SF LEMSA. Provided the patient has capacity, just because you recognize that a patient needs evaluation by a physician doesn’t mean that you can force said patient to be seen by a physician.

        1. Joe, certainly they can, if I am convinced they are able to understand the severity of their condition and understand my treatment plan and reasons for it.  This is often where folks lose sight of what is important.  They start basing their decision on financial issues, not medcial ones.  The SF LEMSA ensures that I treat all patients equally based on their condition and allows me to collect an informed refusal of transport, or an informed refusal against medical advice after consulting with a base physician.
          Tasking someone to a cath capable facility instead of non-cath facility during a significant cardiac event is not kidnapping.
          It is not their intended facility, but specialty care center recognition within the LEMSA dictates that his condition trump his financial concerns.
          Ah, managed care…

          1.  I think that’s where we need to work better with patients. How often will patients agree to a non-network hospital if informed that they’ll have to be transferred anyways when their home facility can’t meet their medical needs. Similarly, I honestly wonder (since I’ll admit ignorance when dealing with health insurance claims) if the paramedic documenting the home hospital request and the reason for pushing for a non-network specialty hospital (including noting the LEMSA designations) would help with the insurance situation.

            In a similar light, how about checking on the other specialty hospitals in the immediate vicinity? Is 5 minutes further going to make a huge difference? Most likely not. Is 5 minutes further to the in-network specialty hospital going to make a big difference if the alternative is the patient refuses a specialty hospital? Most definitely.

          2. Gotta disagree with that last statement about the LEMSA trumping financial considerations. If the patient is competent to make medical decisions, then s/he has the right to place financial considerations above health considerations. IMHO, our only option is to tell the pt that we will only transport to the appropriate facility, that they can go or sign out AMA, and hope they don’t call our bluff…er…hey recognize our concern and agree to go. Truthfully, I’m uncomfortable doing that, but I think it’s the least of evils.

            Just because someone doesn’t share our values (health over money), doesn’t mean we can impose our values on them. All we can do is insist we’ll transport to the right place and hope they’re convinced.

          3. It’s not a values issue at all.  If they make a medical decision for financila reasons do they really understand their condition and are they making an informed decision?  I’d argue no.  But again, if their hospital of choice is closed to ambulances, I can’t take them there so we’re right back to taking them elsewhere.

          4. So your argument is that anybody who would factor financial concerns into a determination of transport (even, say, a $60,000 helicopter ride for the flu), is either not sane or not understanding?

  6. Pingback: Rogue Medic
  7. Taking a patient to Hospital X instead of Hospital Y is not kidnapping. However, as mpatk notes, typically the strongest version of this story (and it’s not a totally unrealistic example) is that the patient says, “Take me to X or I’m not going anywhere.” I gather that you’re suggesting we turn the tables, and say — “We’re taking you to Y, or you’re not going anywhere.” And perhaps this would be okay, although it would be a very strong move in the direction of resource-management versus patient service. Since the underlying goal behind specialty destinations is, presumably, to give the patient the best care, in this case we’re essentially trying to get there through blackmail. We don’t actually think no transport is a good idea; we’re just trying to railroad the patient into going where we believe (maybe quite rightly) they should go.

    In other words, there are three options: 1) Go where we want; 2) Go where they want; 3) Go nowhere. Nowadays, we typically try to talk the patient into #1, and if we fail, then we bring them to #2. As you note, there’s probably no law saying we have to agree to bring them to #2. But if we refuse to bring them to #2, and they refuse to go to #1, then there’s nothing left except #3, or taking them somewhere against their will. Since the latter is indeed kidnapping unless the patient somehow, by hook or by crook, agrees to that transport, presumably we’re left with an AMA. (Or getting somebody to sign a piece of paper saying the patient can’t make his own decisions — a 5150 in your neck of the woods.) And I don’t think that’s what you wanted.

    1. As I said above, the “my destination or AMA” ultimatum is essentially a bluff and plea at the same time. If the patient calls the bluff, the medic is stuck with two unacceptable outcomes: either take the patient to an unsuitable destination, or leave behind a pt who needs medical care and was willing to go to an ED but not the appropriate one.

  8. I commented over at Rogue Medic, so I won’t repeat the entire comment here. I’ll summarize here for those who don’t want to go over there and read it.

    You’re right, he’s wrong.

    For mpatk. The choice will lead to trouble including frequent employer changes is leaving behind a sick person who needs medical care. Go over to Rogue Medic and read my entire not a legal opinion  comment.

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