When does a Person become a Patient? I have had this argument dozens of times and am curious what others have to say. The scenario is you are called to an MVC. Upon arrival you find that no one is injured and there are no complaints. The accident is property damage only. Are Refusals necessary? Why? Does our presence at the incident make them patients, or do complaints and injuries make them patients?

Views: 218

Reply to This

Replies to This Discussion

Well, your duty is to stil check their B/P and vitals. Check head, neck,etc.
If they refuse treatment or a ride get an AMA never know when a call will bite ya back in the butt. Remember CYA!
Actually, it's more like Nathan describes. For you young folks, this wasn't nearly the problem before the advent of the cellphone and what we lawyers call "officious intermeddlers" - people who call in incidents, often without knowing anything at all about what's going on.

A person becomes a patient when (a) he or she calls EMS and and requests help, or (b) when he or she has apparent injuries and someone else called for help. Just because they are a person at the scene of an MVC to which we were called does not make them a patient (at least in our county and according to our protocols). If they answer "no" to "Did you call for medical help?" and "Are you hurt?" then in our world they are not patient. No "refusal," no ePCR, etc.
well unlike the fire dept we still have to check everyone even the green tags. CYA
Chance Gearheart said:
If they were involved in the incident that provoked the call for service in any way, legally they are then OUR patients. In this litigious society, yes, anyone who you make physical contact with gets a refusal signed if they don't want to go. If you do not do this, you've just committed abandonment of your patient.
In the extreme case, does that mean that if a car with 4 belted occupants crashes into a motorcycle and throws the rider, you have to stick around on scene with the biker dying in the back of your ambulance while a second unit shows up to handle refusals lest you "abandon" the uninjured patients? Or is that ambulance allowed to go as long as there's a second one en route to handle the refusals?

Your lawyers have probably told you the truth for your region (let's face it, there are always weird local conditions legally). If so, that sucks--most of the rest of the country doesn't have to get refusals on people who don't want our help and weren't the ones who called.

Of course, there's also a cynical side of me that thinks your bosses have found a way to pad the patient count each year. ;)
Where I work in Indianapolis we are lucky and have a 3rd option, other than SOR/ROT, and nothing. About 3 years ago we developed a one page form we call a CRASH CARD, that has basic demographic information of our "patients." These forms are of course only for the patients that have no complaints (and generally no significant MOI, if my reaction to seeing the car is "that looks liked it hurt" I'd be inclined to at least do an SOR) It also has a place for a signature and a half page tear-out to hand to the patient, explaining to them to call 911 if their lawyer needs a new boat, and that they actually don't have anything to complain about.
The only thing about having them sign a true AMA is that if they're not hurt, is EMS or the command physician they answer to actually going to "medically advise" them to go to the hospital? If command says it's OK to release them, or you say they can be released without command notification, they are not actually AMA, because you can't refuse advise you weren't offered. I know it sounds like I"m splitting hairs, but the point I'm getting at is if these people did not call and obviously not hurt, what are they really refusing? and why?

MK said:
Well, your duty is to stil check their B/P and vitals. Check head, neck,etc.
If they refuse treatment or a ride get an AMA never know when a call will bite ya back in the butt. Remember CYA!
As far as someone here mentioned a second unit to respond to get refusals, that reminds me of something a year or so back. I heard on our dispatch channel an off duty EMT requesting an ambulance to respond to an accident they came across where nobody was hurt...they wished a unit to come to scene to get refusal forms signed. Is it me, or does this seem a little absurd? I mean, if I roll up on an accident off duty, and everyone says they're fine, I don't think I need to call an ambulance to come to scene for the purpose of getting them to refuse services that they know up front they didn't want.
It is a little absurd. It's ridiculous.

And Chance, I guess I'd have to ask you for the legal authority that supports your proposition that everyone at a crash scene is our patient. I've been around and researching this for a long time, and never have heard any such proposition. Remember your basic tort law - duty, breach of duty, damages, and causation. Your duty doesn't begin until the patient requests you to provide service. So, no duty, no tort (negligence, abandonment, etc.). In other words, I think that your statement is incorrect. If a person says "I'm not hurt and didn't request an ambulance" then end of discussion. If they've got an obvious injury, then further encouragement might be in order.

Why some feel that we have to force ourselves on everyone at a scene is beyond me......
I did not realize this subject would cause such a stir. My concern is that anyone who sees "something happen" jumps on thier cell phone and calls 911. I work for a small but extremely busy metro service. The situation is rather common where we are called to incidents where we simply are not needed. This includs everything from minor vehicle collisions to people who trip in stores and "concerned bystanders" are quick to whip out the cellphone and dial 911. I understand the legal ramifications, I would most certainly obtain refusals form any incident with a mentionable MOI, the question was geared toward the simply B.S. calls we often respond to. As trained personnel, I think we should be able to make that distinction when our services were not reqested and not needed.

To throw a further rock in the wheel, in our city we bill for refusals. While some in the upper administration support getting refusals from everyone involved, they do so from a billing aspect, not neccessarily a patient care stance. They would support getting refusal from bystanders who might be "emotionally scared" from the incident if we could. In my view, this is not professional or ethical to induce charges for services that are not needed. This tends to irritate those who are faced with the bills. Any Thoughts ?

Skip Kirkwood said:
It is a little absurd. It's ridiculous.

And Chance, I guess I'd have to ask you for the legal authority that supports your proposition that everyone at a crash scene is our patient. I've been around and researching this for a long time, and never have heard any such proposition. Remember your basic tort law - duty, breach of duty, damages, and causation. Your duty doesn't begin until the patient requests you to provide service. So, no duty, no tort (negligence, abandonment, etc.). In other words, I think that your statement is incorrect. If a person says "I'm not hurt and didn't request an ambulance" then end of discussion. If they've got an obvious injury, then further encouragement might be in order.

Why some feel that we have to force ourselves on everyone at a scene is beyond me......
I agree with your concept, Shannon.

The "officious intermeddler" with the cell phone has really amplified this problem. In way old days (pre-1990) when cell phones either weighed 5+ pounds or did not exist, these type of calls rarely happened. Unfortunately that is when most of today's administrators were on the street. That has warped (or otherwise formed) their professional viewpoints. The "billing for refusals" thing is a whole different thing. If a person calls an ambulance, receives assessment and treatment, and then refuses transport, that billing is fine (although impossible to collect in most cases). If there is a third party in there (even family), then establishing a duty to pay is really difficult. Calling uninjured people who did not call, and bystanders, billable refusals is just plain unethical in my book.
Great question for a forum. This is a frequent topic of discussion in both EMT and Paramedic Class. It also resurfaces frequently in the working world despite written protocols and procedures.
Disclaimer: The fundamental rule is that policies and procedures, protocols, ordinances, administrative codes and statutes that govern the operation of your agency must be known and followed.
Full disclosure: I am not an attorney nor do I play one on TV. (Skip is one of the few real lawyers that are active EMS administrators. Its usually happens the other way around, EMS folks become lawyers and start chasing ambulances in their practice….just kidding.) The following are statements based on 36+ years in the business (from the streets, to admin, back to the streets and back to admin…a long story), attending multiple workshops and seminars on medical-legal issues, formal and informal discussions with lawyers, physicians, educators, administrators, Paramedics and EMTs, reviewing statutes, administrative codes, ordinances and cases on these matters and sitting on the witness stand many times. Granted this does not make me an expert nor do I profess to be one. I am not a “firehouse lawyer”. Just a dude that wants and needs to know the most I can about how and why we can and do the things we do.
The first issue is “When does the patient-care giver relationship begin?” Some will say at the reception of the 911 call. Your duty to respond begins when you show up for work. Your agency’s duty is to respond to all reported incidents and requests for assistance. The guideline that I teach is as follows: When a person presents themselves as being sick or injured and by direct statement or by inference indicates a request for evaluation and/or treatment you have a patient. If as a responder to a 911 call, from whatever the source, you initiate an evaluation of a stated or inferred complaint of illness or injury you have a patient. If you provide any treatment, you have a patient.
If you arrive on the scene of a MVC (or MVA) and all the occupants of the vehicles involved are freely and without restriction moving about and no one motions to you or indicates in any way that they want your services, a patient-care giver relationship has not been established. This last statement does not relieve you of your duty to further evaluate the scene for actual, potential or possible patients. Due diligence must be exercised and contact must be made with everyone involved in the MVC to determine if there is a patient. Making contact to ask if an occupant of a vehicle is injured does not establish the patient-care giver relationship. A scene assessment does not equate to a patient assessment. A scene assessment is to determine if there are any patients. It is their direct statement or inferred actions and behaviors in association with your observations of them and the scene that indicate a desire or need for an assessment and/or treatment. The patient-care giver relationship has then been established. If you conduct an assessment of a person to determine if they have any injuries or are in need of treatment and/or transportation to a hospital, you have a patient.
A patient signs a refusal (See above as to who is a patient). Read your agency’s refusal (or AMA) form. They vary from agency to agency. Know what your agency’s policies are for refusals. Know what you are asking people to sign. Make sure the patient knows and has the capacity to understand what they are signing; they must be physical, mentally, psychologically and legally able to understand and sign. Document, document, document your assessment. Document, document, document any and all treatments provided. Document, document, document the conditions and situation in which you left the patient. You must be able to recall the incident years later from what you documented. The quagmire thickens in what you didn’t document.
PCRs (patient care reports) are for patients. But many agencies have one form that serves as a response report and as a PCR (such as the one for which I work). Know your agency’s policies. The key is that every response must be documented.
A person becomes a patient when that person meets your agency's written definition of the elements that constitute a patient. As Skip points out, we don't have the legal right to force ourselves upon people that are not injured and don't want our "help".

If everyone at the scene states that they are not injured and didn't call for help, no has any apparent injury, and everyone can verbalize the elements of present mental capacity, then there's no patient and no need for a waiver. The first element of documentation is to tell dispatch the situation found and get the status documented on tape. Describe the situation in your report.

If your agency doesn't have a written definintion of the elements that make a person a patient, then you're going to be in trouble in court regardless of who you transport and who you don't.

Reply to Discussion

RSS

Follow JEMS

Share This Page Now
Add Friends

JEMS Connect is the social and professional network for emergency medical services, EMS, paramedics, EMT, rescue squad, BLS, ALS and more.

© 2016   Created by JEMS Web Chief.   Powered by

Badges  |  Report an Issue  |  Terms of Service