Where do you live that the community ED would be able to assemble the supplies for a chest tube in 2 minutes, let alone put it in? I'm quite jealous! :DWhat do you do? Stop at Suburban Hospital and have ER Doctor place a chest tube (1-2 minute procedure)
Thanks for the response. It was interesting to see two polar opposite views on self determination (which, by the way, I do agree that patient's choice trumps all within reason) from lawyers in the span of a month.
I'll throw a curve ball to the board.
You have a patient who has been put under a psychiatric hold (i.e. Baker Act, 5150, Section 12, etc depending on location). The patient is requesting a different hospital than the one that the authority that is placing the hold. For the sake of argument, both facilities have inpatient psych facilities, both hospitals are within a reasonable distance, and the patient is being cooperative. How far, if at all, do you pursue changing destinations?
Hey Ken, I appreciate your answer was aimed for Skip, but as we face a similar situation here, I don't know whether I can have a go at furthering the discussion.
I think the problem that we have in EMS as a whole, its not just US specific, is the principle of INFORMED consent. A lot of providers go in "it sounds like your experiencing condition X so we need to pop you to see a doctor" and then they wait for the patient to say "yeah I agree" or "No it'll be alright". It's the "No" or the "Yeah...BUT" that causes us as providers considerable headaches. Mainly because we're not trained or have the detailed knowledge to explore the patients concerns further.
If an ALS Fire engine shows up on scene and deems the patient is not ALS but BLS, they do not have an obligation to transport the patient. They can call for a BLS transport unit (often a private ambulance company). In a very real sense they are declining to transport the patient.Now what if the patient insists to go with the Fire department transport rather than waiting the BLS transport unit? Are you somehow violating the patient's right of self determination by not allowing them to be transported by WHO they wished to be transported by?
I don't know if they are declining to transport, more creating an alternative care pathway. Our managers in the UK push us to identify patients that don't need ALS transport and to call for a BLS unit. The dispatchers don't like it because they are deploying 2 resources to the incident. I think we need to explore why the patient does not want the BLS/private transport. Could be that they've had a bad experience in the past? In our service, its trying to explain why we can't take them now, "you're an ambulance crew, can't you take us" Patients having called an emergency, expect an immediate response, so by then saying you'll need to wait an hour for someone to come and take you to hospital, will result in the most part you leaving scene and 10 minutes later the patient dialing emergency again.
So by exploring the patients rationale for the decision they have made, will help us to better care for them. Giving them the information about the rural service level and depletion of vehicles may help them to understand why a different ambulance will take them to hospital. Although personally I feel that service depletion is not a valid reason to make alternative transport arrangements, I see a situation where patients will be tagged BLS when really they should be ALS. (Not suggesting that happens in your case, but a level of risk nonetheless in two tiered services)
Is it going against self determination? it depends whether we have offered the patient all the information they need to make an informed decision. If we haven't and go ahead and implement something to suit our own needs then I believe that is as has been previously discussed EMS forcing care on the patient.
We have determined in our protocols that the patient will go to the nearest appropriate facility for the simple reason that we do not have the manpower to send trucks out of service to far off and exotic destinations although we do make every effort to transport the patient to their destination of choice we will not accomodate an unreasonable request.
This is for the most part the same as most EMS agencies, In our service, we have a specialist cardiac hospital. People who live in the area, that call with Chest Pain, Palpitations, Shortness of Breath, immediately want to go to the hospital. Our service has agreed direct admission pathways, for MI's, Exab of COPD, CHF and arrythmia's. IN all other circumstances, an average crew say we'll pop you to the emergency department and the patient says I want to go to XYZ hospital. Most crews then say, "you can't" and leave it at that. This smacks of the paramedic forcing judgment on the patient, the common sense if you like. Taking away, the patients right to choose.
But by first giving the patient the reasoning and information, and creating options in a non emergent situation the GP can attend and make admission to the specialist hospital rather than immediate transfer to the emergency room. Balancing risk against reward can allow the patient to understand the crews point of view and make an informed decision on their healthcare needs.
It becomes an issue when crews follow the "yeah BUT" up with an "errr NO" rather than an "OK, I appreciate that, let me explain my thinking..."