Ethics, the law and playing the odds
A drunk is not "just" a drunk
By David Givot
I'm beginning to empathize with Sisyphus. In Greek mythology, he was punished by being forced to roll an immense boulder up a hill, only to watch it roll back down, and destined to repeat this action forever.
That is what it feels like when I hear stories about paramedics who dismiss patients based on what they "think" or "assume" is wrong, rather than what a full assessment shows.
My wife is an RN/MICN at a local trauma center. In addition to treating patients, she spends much of her day answering paramedic radio calls, taking reports, giving field treatment orders, and consulting the appropriate receiving facilities. She comes home tired every day and her stories often begin with: "You are NEVER gonna believe this…"
For the record, she never shares enough information for me to have any idea who she is talking about and she won't tell me which medic units or agencies are involved. She does give me just enough information to shake my head and wonder.
The other night, she came home and recapped a call that led to a heated "discushment" (as my daughter used to call it) with a medic who was mad because she required that a patient with head trauma and ALOC be transported to the trauma center.
The radio report was pretty much this: An older guy, mid 60s, was found in a toilet stall of a fast food restaurant with a needle sticking out of his arm. He was awake, but unable to answer questions properly. Even after 2mg of Narcan, he knew his name, but could not say where he was, what day it was, or even his own birthday.
His vital signs were all within the normal range and his extremities seemed to move with equal strength – though there was no report that a grip and pedal-push exam was performed. His speech was slurred. He had a laceration on his scalp, but he did not remember falling or getting hit or bumping into anything. "I don't know how that happened," was all the explanation he could muster.
Seemingly expecting to end the radio call, the medic ended the report with: "Our closest receiving hospital is [name withheld] with an ETA of eight minutes."
My wife, the MICN (who has been listening to me preach about high-quality and appropriate patient care for years) was not quite ready to sign off. She inquired further into the mechanism of injury and the altered level of consciousness. The medic, demonstratively exasperated, let her know that the patient probably just fell in the toilet stall and was known by them to be a drug addict, a drunk, and a frequent flyer; that he would be just fine at the closest receiving hospital.
She consulted briefly with the ER physician, who agreed that there are too many possibilities with an altered/head-injury, then asked: "Just the same, [name of unit withheld], what's your ETA to th nearest trauma center?" A gruff, frustrated voice replied: "[name of facility withheld], you would be our closest trauma center with an ETA of 13 minutes, but I don't think a trauma center is necessary and…." With that, the radio transmission ended.
The nurse replied, "I understand; however, just to be safe, go ahead and transport the patient to [trauma center name withheld] and we will see you here in 13 minutes…." That was followed by the supplemental treatment orders and the unit signed off.
When the unit arrived, the patient was received in the trauma bay, evaluated and treated accordingly. The call should have ended there. It didn't.
Moments after the patient arrived, the medic was in the radio room, in the nurse's face (I don't even do that) contesting the trauma center transport order. His arguments included: "You took us out of our area and it is busy out there today," "You should trust what we tell you," and "We go on that guy every shift, he's a junkie and a drunk."
I'm not quite sure how to be diplomatic about this, so I am just going to offer my opinion as a professional who sees EMS from all sides:
NO! NO! NO!
First, while it may be a busy day, there is only ever ONE call; the call that you are running at the moment. EMS is a first-come-first-served business, and no other call relieves you of all the duties you owe to the call you are on.
Next, how can any reasonable provider expect to be trusted or even taken seriously when they disregard assessment findings or fail to understand the concept of "err on the side of the patient?" Moreover, who is going to trust the provider who fails to see or completely ignores the possible connection between a head injury and an altered level of consciousness?
I get it. More often than not, what you see is what you get; an altered junkie on a toilet seat is probably exactly that. However, playing the averages or simply assuming is not part of the job. The job is functioning as if nothing is what you think it is until you prove – to the best of your scope of practice – that it's true.
If you don't believe me, check out Zepeda vs. City of Los Angeles1 or Wright vs. City of Los Angeles2 or Hackman vs. AMR3 and you will see how the law views the duties of an EMS provider.
Finally, and I cannot believe I still have to say this in 2013: a drunk is not a drunk! Just ask Sarah Schulman4. In fact, for an EMS provider to assume that a drunk is just a drunk is being arrogant to the point of dangerous.
The function of EMS exists almost entirely in the grey area between what could be and what is; between what's possible and what's likely; between what we hope for and what we are afraid of.
The law of EMS, on the other hand is very, very clear: There is an absolute duty to fully assess, properly treat, and appropriately transport or correctly release every patient. Where there is doubt, the law is written in the blood of those who failed before you: err on the side of the patient.
The scariest thing may be that every EMS provider knows erring on the side of the patient is an absolute requirement…even as they are ignoring it.
1. Zepeda vs. City of Los Angeles (1990) 223 Cal. App. 3d 232 [272 Cal. Rptr. 635]
2. Wright vs. City of Los Angeles (1990) 219 Cal. App. 3d 318 [268 Cal. Rptr. 309]
3. Hackman vs. American Medical Response, 2004 WL 823206 (Cal. App. 4 Dist.) (Unpublished Opinion)
4. Schulman vs. Regents of UC, et al. B195349 Court of Appeals of CA, Second Appellate District, Division Two