You Make the Call – Bit – Part II

Let’s recap:

We’re miles from the nearest ambulance, 35-45 minutes from the arrival of the first response unit and a now rapidly swelling index finger from a snake bite.

The Coleman Brand Snakebite kit is a small package of provodine, a scalpel and a little sucker tube.  More or less useless unless we were hours from help.  We’re far, but not nearly THAT far.

One of the moms has the rangers on the phone and they’re en route, advising us not to take any action.  They’ve got a small BLS bag and arrive soon after we heard them running sirens on the mountain road.

The Rangers gather their patient’s basics and make a decent attempt to take a blood pressure when I suggest ever so gently that perhaps time is of the essence and an intercept with the responding ambulance would be a good idea.

“We can’t transport him.”

No, you can, you just can’t bill for it, or call your vehicle an ambulance.

“Oh, OK” was what came out of my mouth.

A patient update has been sent and when I realized the decision that had been made only one thing crossed my mind:

I wish Rogue was here to see this.

The helicopter was already circling, less than 10 minutes since the gentleman wandered into camp and at the rate the edema was intensifying even a ground intercept was going to be cutting it close.  The initial edema didn’t seem so bad, but now you can almost see it creeping slowly past the second knuckle with no sign of slowing down.

All my breathing coaching is helping a bit, but I was later informed of the reason his pulse rate increased:

He has no insurance.

 

The landing was fast, they didn’t wait for an LZ to be set up, just picked an empty campsite around the corner and did their thing.  One of the rangers drove off to check on them, code 3 of course, and came back moments later.

“Get him in here I’ll drive him over to the chopper.”

Chopper?  Really?  Oh well.  Suddenly we CAN transport, and I remind the patient to stay calm and let the nurse and medic know about any dizzyness, numbness, trouble breathing, the big stuff and away he went.  Another few moments later we hear the helicopter throttle up and tilt the rotors and away they went.

Now imagine he hears the helicopter and tells you there’s no way he’s going with them and asks you to drive him to the ambulance.

What would you do? You Make the Call.

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3 thoughts on “You Make the Call – Bit – Part II”

  1. Since I have seen a patient refuse air transport once in the past I think that it would be OK.  But, it is only OK if you know that the patient would not suffer any detrimental effects from delayed intervention at the ER.

    The one patient I saw refuse was while working an an Advanced EMT.  After my Paramedic partner had called for the helicoptor and the patient, a Trauma Surgeon home on leave from Iraq, said he did not need that and he would go in the ambulance we transported by ground.  Those are two different situations and in the spirit of covering your arse as an off duty Paramedic you would be serving yourself and the patient better by convincing him to go with what is available.

  2. Oy…  That little clause in our job description, from EMT-B all the way to Paramedic that says we have to act “in our patient’s best interest” would compel me to attempt to reason with him, and suggest he fly with the chopper, ability to pay be darned.  However, as long as he’s mentally intact, legally I can’t compel him to do anything, even if it would save his life.  He just has to be able to make a informed decision, which means he must be told what the full consequences of his refusal would be.  Our inability to kidnap/compel really sucks sometimes (kidding…kidding…)

    The good thing is that in the grand scheme of things, rattlesnake bites to adults are usually (usually…) not fatal.  If he refuses to go and decides to ground transport (or have someone in his group self-transport), he’ll definitely suffer a great deal of pain, tissue damage, continuing side effects, and lots more “scary symptoms,” but he probably won’t die.  

    I don’t know what the laws are like in California, Happy, but here in VA you’re off the hook as far as duty to act and duty to convince your patient to accept care.  In VA, while off duty, EMT’s, Paramedics, and Firefighter’s have no duty to act, and any response is, at that point, a good faith effort covered by the Good Samaritan laws (as long as you stay within your scope of practice.  If you attempted “swiss army knife brain surgery,” you’d be in a different position).  Most of us will, of course, offer help (ethical thing), just like you did.  In this case, it would be the responsibility of the flight crew and the rangers to deal with the acceptance/refusal of care; you would essentially be a glorified bystander (no offense :D).  

    1.  Indeed, Duty to Act includes one very important part…representing an agency.  California is locked in an 1848 idea that each County should separately certify their own Paramedics, meaning I couldn’t act even  on my drive home through 2 other counties if I wanted to.
      In this situation I was John Q Public and could convince him to buy Life Insurance if I wanted to.  had he asked me what to do, I would have told him to listen to the Rangers.  THEY have a duty to act and if I interfere I can be detained at the scene for interfering.
      Our inability to “kidnap” is an urban legend.  We kidnap all the time, but more appropriately, we are kidnapped all the time by patients who don’t need us, yet force us to take them somewhere against our will using intimidation (threat of legal action).  That definition fits better.

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