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

- Rogue Medic

Sign the Refusal Form, Ask Them To Leave, and Drive Him To the Hospital – EMS Patient Perspective

 
At The EMS Patient Perspective, Bob Sullivan writes about one great example of EMS incompetence. Unfortunately, it is a personal one.
 

She had called 911 for my grandfather, who was entering his later stage of dementia, and had passed out. In the background I heard a paramedic from the company I used to work for explain that his blood pressure and EKG were normal, that he did not need to go to the hospital in an ambulance, and that it was safe to drive him themselves or follow up with his doctor on Monday.[1]

 

But if we tell them to go away, what happens if something changes on the way to the hospital?

Unless the bad outcome is something as blatantly obvious as a cardiac arrest, these less than competent people are probably only going to make things worse.

Even if it is a cardiac arrest, they might not treat the patient appropriately. I have had a very experienced medic (been around for a long time, but apparently only had a single day of experience thousands of times over) ask me why I was defibrillating a patient with obvious ventricular fibrillation on the monitor.

Another decided to move the patient to the ambulance to intubate after he placed the tube in the esophagus and the patient began vomiting. No suction. No ventilation. Just carry the patient with the obstructed airway out to a place where he felt more comfortable.

Would this EMS squad be any better?

We have no reason for confidence in their abilities or judgment.
 

Syncope is a true emergency.

A lack of arrhythmia does not mean that it is not an emergency.

A lack of abnormal vital signs does not mean that it is not an emergency.

Many patients will not end up with a definitive diagnosis after treatment in the ED (Emergency Department).

Did the medic(s) apply the San Francisco Syncope Rule to determine that this patient does not need to go to the ED?
 

Clinical decision rule

Five risk factors, indicated by the mnemonic “CHESS,” were identified to predict patients at high risk of a serious outcome:

  • C – History of congestive heart failure

  • H – Hematocrit < 30%

  • E – Abnormal findings on 12-lead ECG or cardiac monitoring17 (new changes or nonsinus rhythm)

  • S – History of shortness of breath

  • S – Systolic blood pressure < 90 mm Hg at triage

Note: ECG = electrocardiogram.[2]

 

I doubt that the medic(s) ever even heard of the San Francisco Syncope Rule, but even if aware of it, here is how it should be applied.
 

The San Francisco Syncope Rule should be applied only for patients in whom no cause of syncope is evident after initial evaluation in the emergency department.[2]

 

Only
 

   after
 

       evaluation
 

           in the ED
 

               should we even begin to consider syncope to be a non-emergency.
 

If I search in the dark, with no light, for a black cat and cannot find the cat that really is there, does that make the cat disappear?
 


Image credit.
 

To proclaim that it was safe to leave my grandfather home after a five minute assessment and one set of vital signs was negligent.[1]

 

That should be obvious to everyone.

To every medical director.

To every medic.

To every basic EMT.

To every police officer.

To every mail carrier.

To every drunk not yet passed out on the corner.

This is a failure of EMS education, management, and medical oversight.

The easiest way to get rid of the dangerous people who do not understand this is to sign the refusal form and get them as far away from people they may harm as possible.
 

What if the patient (or family) do not want to go to the ED? That is entirely different and would require several posts to cover.

Footnotes:

[1] Sign the Refusal Form, Ask Them To Leave, and Drive Him To the Hospital
November 6, 2013
The EMS Patient Perspective
Article

[2] San Francisco Syncope Rule to predict short-term serious outcomes: a systematic review.
Saccilotto RT, Nickel CH, Bucher HC, Steyerberg EW, Bingisser R, Koller MT.
CMAJ. 2011 Oct 18;183(15):E1116-26. doi: 10.1503/cmaj.101326. Epub 2011 Sep 26. Review.
PMID: 21948723 [PubMed – indexed for MEDLINE]

Free Full Text from CMAJ.

.

Comments

  1. This blog is my new favorite thing. Seriously. 🙂

  2. Great post… for some reason, syncope seems to be a misunderstood entity by providers, and also medical directors.

    In my system, a syncope patient is required to have his BGL tested, but no 12 lead. The number of providers who do a 12 lead on syncope patients is small, and when I do it, I am often asked “why” by medical control. Of course, their BGLs are almost always normal (when they are alert and oriented), but what’s on the ECG is often never known.

    I have heard this exists in other systems, but I can only speak about mine. Has never made any sense to me.

    Dave B

  3. Thanks! I thought this might grind your gears.