Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

EMS case law? AMA Refusals, Death, and Documentation – Life Under the Lights

Ckemtp writes EMS case law? AMA Refusals, Death, and Documentation

It is important to read. This is also a job for Star of life Law – a real lawyer. I am not a lawyer, but looking at the legal paper, it seems that this is just a determination of whether the law suit can proceed. If the original judge ruled that there were no grounds for a suit, then there probably had not been a presentation of a defense. That would happen during discovery (which may have been concurrent) and trial.

This ruling seems to be – the plaintiffs can proceed with their suit. The trial may still be a long way off.

What is described in this ruling from the Court of Appeals is superficially scary.

15 minutes on scene, for a patient who died less than a day later. Sounds bad, but we don’t have any of the information to explain why.

Did the medic incompetently blow this off as indigestion?

I don’t know.

Did the patient threaten them and chase them from the home?

Probably not. It doesn’t seem that way, but we do not know.

I spend much more time on refusals than almost any other call, although I have spent over an hour on scenes getting patients’ pain to the level where it was not torture to move the patients.

I have even had a refusal from a patient presenting with what gave every sign of being an MI. I showed him the ST elevation. He was a cardiologist. He absolutely refused. I have no idea of the scene time, but I got everybody there to try to persuade the patient to go to the hospital. I got medical command to talk to him, even though this was in a place where the doctors don’t talk to refusals. I’ll talk to this patient, but we don’t do that here. WTF?

I never heard anything further about this patient. It was an ALS assist outside of our territory. I checked the obituaries a couple of times, but this was when that required buying the local paper, or going to the library. As a library addict, I stoned a couple of birds in one shot. No dead doctor.

The part that does not look good is this.

What emergency physician is arrogant enough to discharge a patient with only a 12 lead ECG?

And we don’t even know if they did a 12 lead ECG.

Can we diagnose an MI/STEMI/NSTEMI with just a 12 lead ECG?


Does that mean that we can rule out an MI/STEMI/NSTEMI with just a 12 lead ECG?

Absolutely not.

A positive finding means something.

A negative finding only means that at the time the 12 lead ECG is performed, the patient is not having a heart attack that can be detected by a 12 lead ECG. A negative finding does not mean that the patient is not having a heart attack.

Consider that you are in the woods. It is cold and you are seeking shelter. You see a cave. It is dark in the cave. If you heard growling coming from the cave, you would have a positive finding that there is an animal in there.

If you cannot hear anything, or see anything, does that mean that there are no animals in the cage – nothing big enough to reach out and bite you?

Unless the test has excellent sensitivity, a negative finding only means that nothing was detected. It does not mean that nothing was there.

If you could see through the walls of the cave, you could be sure if there were any animals inside, what kind of animals, how many animals, and many other things. In EMS, we do not have that kind of diagnostic equipment. Waveform capnography may be the closest we come.

It may be nice to tell someone that everything is OK, but it is just a coin flip on whether we are right.

That is not even close to competent.

Will an emergency physician also check cardiac enzymes and still worry that he may be discharging a patient with a real heart attack?


One other thing.

The cause of death was not a heart attack.

The cause of death was pulmonary embolism.

Maybe we do an excellent job of ruling out a heart attack. Yippee!

That does not mean that the only other cause of chest pain and difficulty breathing is indigestion.

We should never approach a patient assuming that the cause of any complain, even abdominal pain, is indigestion. Even if the patient is mixing 5 alarm chili, donuts, beer, chocolate milk, whiskey, candy corn, a soufflé, and a bunch of other food that gives us indigestion just looking at the combination. Even if this patient has GERD and ulcers.

I do not believe in telling lies to patients.

If you don’t go to the hospital, you’re going to die!

If the patient does go to the hospital, the patient is still going to die. Everybody dies. So?

I explain the reasons the patient may want to go to the hospital.

I explain the limitations of my assessment.

I explain whatever they ask (related to the call).

Sometimes (frequently) my answer is – I don’t know.

Refusals require informed decisions.

Treatment and transport also require informed consent, but we seem to ignore that – a lot.

How many of us obtain informed consent for spinal immobilization, or even an IV start?

How many of us would be able to provide accurate information for a patient to be able to make an informed decision to consent to treatment/transport or to make an informed decision to refuse treatment/transport?

If we do not do a good job with informed consent, are we surprised that a lot of refusals are not well informed?



  1. I also posted this over at Ckemtp’s site.

    This opinion does NOT state that a “signed refusal means nothing.” This opinion does NOT deal with informed consent. This opinion does NOT deal with patient refusals AMA.

    This opinion DOES deal with Official Immunity of a publicly-employed medical professional IN MISSOURI. And only that.

    This opinion is from an appeal of summary judgment from the trial court. Summary judgment motions are typically heard fairly early in a case’s life. The paramedics and the department moved the Trial Court to dismiss the case via summary judgment on the grounds that they were immune from suit under Official Immunity. The trial court agreed with them, granted their motion and dismissed the case. The plaintiff’s then appealed the dismissal to the appeals court.

    From a legal standpoint this is not a big deal, in my opinion. The appeals court denied Official Immunity because they determined that the first call was not a “true emergency situation.” The Court of Appeals has remanded the case back to the trial court, where presumably, the case will continue on negligence and wrongful death grounds. The defendant’s may also appeal this ruling to a higher court (and likely will) prior to that though

    I highly doubt that the defendants entire case hangs on this technical point. They will fight the negligence and wrongful death claim.

    The reason you raise issues like Official Immunity, is because if you can’t be dragged into court to begin with, there is no utility in wasting time and money preparing for a full defense on the merits.

    The presence or absence of an Informed Refusal AMA will go to the heart of negligence and wrongful death, and is of really no consequence for consideration of Official Immunity, hence why I believe it is not discussed in this opinion. A refusal is immaterial to consideration of Official Immunity.

    For the seminal primer on Informed Refusals and Present Mental Capacity of Patients, Google Gene Gandy.

    Star of LIfe Law


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