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

- Rogue Medic

Up To, and Including, DEATH – The Anguish of Happy Medic


Happy Medic explains that in reviewing refusal of transport charts, he comes across this magical invocation repeatedly.

This is a phrase I see a lot in my line of work. There are a number of variations including another favorite “seizure, coma, death” that are designed to cover the hind quarters of the author in some half cracked attempt at documentation.[1]


Even Sylvester Stallone correctly ridicules seizure, coma, death reasoning, so evil it must only be be spoken of in the most reverent terms.


Happy Medic has a question for those who use either murder, death, kill seizure, coma, death or Up To, and Including, DEATH as a part of their documentation of a refusal for minor injuries.

I confess that I was trained to do this and it took me a while to realize how ridiculous it is.

Funny part is that this blanket statement calls into question the rest of your document most times. Do you really believe the hand abrasion will lead to death? In what fashion? If it is such a risk, why isn’t the patient being transported?[1]


Please, explain how this laceration will lead to death.

This must be a death that would be prevented by immediately taking a magical trip to the ED (Emergency Department) by our magic carpet ambulance.

In the ED, they are able to use stronger spells than seizure, coma, death. 😳

What we are trying to state is I am not responsible.

This seems to be the motto of the least competent in EMS.

If I follow the protocol, I am not responsible for the harm I cause the patient.

If I follow medical command orders, I am not responsible for the harm I cause the patient.

If I follow orders, I am not responsible for the harm I cause.

Is that really what we aspire to?

If people enter EMS with this attitude, we should do our best to get rid of this attitude.

If people enter EMS without this attitude, we should do our best to get rid of those of us encouraging this attitude.

EMS is not magic. We are not magicians, sorcerers’ apprentices, or flying monkeys.

We are pretending that magic is a solution to ignorance and/or incompetence.

The I am not responsible attitude is dangerous to us and dangerous to our patients.

Please stop being dangerous.

Go read Happy Medic’s solution to this magical incantation.


[1] Up To, and Including, DEATH
Jan 23, 2014
Happy Medic



  1. It’s a CYA, actually- you don’t think it will cause the patient to die, but there is a non-zero chance, and the higher-ups don’t want to have to deal with arguing in court over if it was incompetence on the part of the meedic not to transport anyway or not. with the warning of the possibility of death in the documentation, it reduces the risk of a lawsuit. It’s more a comment on the sue-happy culture these days than on the medic.

  2. sstabeler,

    I thought that Happy Medic made it clear that this kind of documentation makes the person writing it look foolish.

    I agree.

    Foolish documentation probably makes it more likely that someone will sue you.

    Who is more likely to be negligent, the one who consistently makes indefensible statements, or the one who makes defensible statements?

    If you expect to be sued, why make statements that make you look like you deserve to be sued?


  3. My county has a useful way to deal with this issue. It has both an Against Medical Advice (AMA) and a Release At Scene (RAS) section. The AMA is the traditional “you may die if you don’t go with us” verbiage. The RAS states that the patient should be seen by a physician/ED/clinic; but an ambulance is not necessary.. That way, there is an intermediate that acknowledges that just because a patient should see a doctor, s/he doesn’t need emergency transport.

  4. Upfront, I will admit that I’ve used similar phrasing and thought it stupid at the time. I think a big part of this comes not just from the litigious nature of US society, but in the uncertainly in the litigation process.
    I can just see it now: a minor cut which is treated with a 2×2 and tape. Done. However, a small clot gets jostled and makes its way to the brain leading to COMA and DEATH!
    On the witness stand:
    “Did you let my patient know that they could have died without advanced medical treatment?”
    “No – that’s highly unlikely and would only cause extra anxiety for the patient.”
    “So unlikely that it … happened this time? Tell me, how do you explain that to her Poor, Orphaned children?”

    That’s the problem – the odds of death occurring are pretty much the same as the odds of me having to testify about it.


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