Is Your Empty Ambulance Loaded with Liability?

Patient refusals requires professional ACTION

Providers who have been involved in EMS for more than a day know that not all 911 calls result in a patient transport. My personal experience is that maybe half of the 911 calls I have responded to actually required paramedic intervention — much less, ALS transportation. Your area is probably not too different in that respect.

I am willing to bet that your load of calls for things like emotional upsets, persistent low-grade fevers, blistered feet or false alarms is equally offset by chest pains, altered LOCs, seizures or strokes. Likewise, I am sure that you have your share of well-known “frequent flyers” and specific call types that can be predicted with almost supernatural accuracy.

However, while real medical problems require and receive your utmost attention and skill, it is actually those minor or predictable calls and false alarms that hide the greatest danger.

Let’s agree from the beginning that not all emergency responses require transportation to the closest emergency department – or anywhere for that matter. Let’s also agree that every emergency response, no matter how ridiculous on the surface, demands and deserves the full attention of the responders.

With that, let’s take a look at the dangers when deciding not to transport, and what providers can do to ensure that this decision is best for the patient and reasonably safe for the provider.

There are essentially three situations where an emergency call does not result in transport: the false alarm or the person with no complaint at all, the patient is in little or no [medical] distress, and the legitimate or potentially critical patient who refuses transport. This is the toughest situation because it firmly places the provider between a rock and a very hard place.

In any situation, the decision to transport or not is always a matter of ACTION.

  • Assess
  • Consider
  • Talk
  • Introduce
  • Offer
  • Note


While every call may not result in a patient transport, every call must result in a comprehensive, complete and consistent assessment. Notice that I said “assessment” and not “patient assessment.” The distinction will become clear in due course.

Where there is any medical complaint…
Where you are called to a person with any complaint at all, the assessment element of ACTION is easy: you will complete a full line of questions, gather a full set of vitals, conduct a full (relevant) physical exam, and carry out a full inquiry into history along with environmental and secondary concerns. Anything less is not a complete assessment.

Where there is no medical complaint…
On the other hand, where the call to 911 may have been a mistake or there is no medical complaint, the assessment element of ACTION can be somewhat trickier; after all, how does one assess a non-complaint? You don’t. Instead, you assess the situation; you shift from paramedic mode to detective mode and do what you must to get to the bottom of the situation.

In cases like this, your “assessment” should include questions into why 911 was called, who called, who and where is the subject of the call, and was there a complaint that is now being denied? By virtue of your presence in response to a call for help, you have an absolute duty to apply all of your knowledge, skill and experience to the situation so that you can act in the best interest of whoever may need you.

Believe it or not, this is where I have experienced the most resistance from field providers. I have heard it all: we’re too busy; it’s a waste of time; if they tell us nothing is wrong, nothing is wrong; I’m a paramedic, not a babysitter; and the list goes on.

However, the law is not interested in your sentiments on why you are there. Your job is to confirm and be reasonably sure that there is no problem. Therefore, you are not too busy, it’s not a waste of time, and something is wrong until you reasonably conclude nothing is wrong. And if you regard erring on the side of caution as babysitting, then you are in the wrong profession.

Once you have completed the appropriate assessment, you must consider the possible causes and consequences of the issue at hand.

Where there is any medical complaint…
This is the easy part. Where there is any medical complaint at all, you must glean the possible causes from your assessment in concert with your knowledge and skill. You would do this anyway, otherwise how would you know what treatment, if any, to initiate? Likewise, you must consider the consequences of not treating or transporting based on the same.

Where there is no medical complaint…
Consideration of causes and consequences takes a different spin. For example, if the “cause” of the 911 call truly was a mistake, then the “consequence” of non-transport is nil. However, where the cause of the call is something that the caller or some ancillary party is now trying to cover up, the consequence of non-transport (or at the very least, further investigation) could be catastrophic. If it was reasonable for you to inquire, based on the totality of the circumstances, but you didn’t, then subsequent harm may be imputed to you.

Take the time to talk to the individuals involved about the assessment, causes and possible consequences, then discuss what they want and why.

Where there is any medical complaint…
Remember that medicine is a mystery to most people and patient care delivery systems are foreign environments to almost everyone on the outside. There is a general perception that lengthy emergency room visits or extended wait times are the product of incompetence and poor management. We understand that there are numerous processes involved in accurate diagnosis and proper treatment and those processes take time. The same is true in the EMS setting. The blips and squiggles on an EKG screen have no intelligible meaning to most patients or their families. Terms like systolic, diaphoretic, and tachycardic are essentially meaningless.

When you find yourself confronted with the possibility of a non-transport, take the time to talk with the patient and those involved about what your assessment reveals, as well as the possible causes and consequences of whatever you found or didn’t find. Include the patient in the whole discussion, not just the part about you not transporting. Remember that you are there to provide what they need – especially when they don’t know what they need.

Where there is no medical complaint…
The discussion may be different, but there is a discussion nonetheless. Once you have assessed the situation completely and considered the causes and consequences, take the time to talk to the individuals involved about the situation. It may call for some education on how and why the local 911 system works or something more specific to the circumstances at hand. Whatever the case, take advantage of the present opportunity to help the parties involved understand and manage whatever it was that led them to call 911.

After assessment, this may be the most important step in the process. Once you have completed your thorough assessment, considered the possible causes and consequences, and talked with the patient or parties about what you have found, introduce the alternatives, risks and resources that are available.

Where there is a simple or non-critical medical complaint…
You are called to the park, where a 19-year-old male has twisted his ankle playing frisbee golf. The only pertinent finding from your assessment is some mild swelling at the lateral aspect of the right ankle with some associated reddening. All distal pulses are present, neuro/motor functions are intact, and capillary refill time is normal. However, the patient’s insurance requires a significant co-pay for emergency room visits, but he may be seen at a local urgent care without any cost whatsoever. The patient tells you that he would rather have his friend drive him to the urgent care than go with you to the ER.

This scenario is very common and not too challenging. It is your opportunity to introduce various considerations for the patient to weigh. For example, the urgent care may be sufficiently equipped to manage a minor soft tissue injury or even a simple fracture, while the ER may be better prepared to handle a more complicated fracture – if such is the case. The urgent care may be adequately equipped to shoot and analyze X-rays, while the ER may have MRI capabilities. In the end, based on this particular scenario, the urgent care seems like a very appropriate decision and the patient has had an opportunity to consider the pros and cons.

Ultimately, the idea is to assure that the patient’s decision – and your decision – is both intelligent and informed.

Where the patient is critical…
You are called to the home of a 75-year-old female who is complaining of acute, non-provoked, sub-sternal chest pain, a 9 out of 10, with radiation to the left arm and jaw for the past 1.5 hours. Her skin is pale, coo, and diaphoretic and she is short of breath secondary to the chest pain. Her pulse is 100 and irregular and she is borderline hypotensive. The EKG reveals multifocal PVCs at a rate of 20 per minute. She is fully alert and oriented and insists that it is just anxiety and refuses any treatment or transport to the ER.

This is the time to introduce her to the risks, consequences and alternatives available to her. Of course, death is high atop each list. This is the time to be as firm and persuasive. This is also the time to introduce her to the other resources you have available. Contact your base hospital and have the MICN or MD speak directly with the patient. If friends or family members are around, have them do what they can to convince her to go with you. Look around; take clues from what you see in the home. If she appears to have hobbies or outside interests, exploit them. If there are photos of children and grandchildren, introduce her to the likelihood that she will never see them again and how much she will be missed.

The bottom line: introduce her to every tool you have to convince her to go with you to the ER – you’re there to address needs more than wants, and she needs to go to the ER.

Where there is no medical complaint…
Once you have taken the requisite foregoing steps, it is time to introduce the parties involved to whatever associated risks, resources and alternatives they may have available.

For example, the risk of calling 911 instead of 411 is that someone who truly needs emergency help may not receive it in time. Also, the phone book and internet are loaded with resources that may be more appropriate than 911 in certain circumstances. Lastly, friends, family and some public agencies may be suitable alternatives to 911. Remember, though, you are helping and educating, not scolding and lecturing.

While it may seem somewhat counterintuitive, always offer transportation – even where no transportation is called for. That’s right, even where no transportation is called for.

Where there is a medical complaint…
This is a no-brainer. If there is a medical complaint, no matter how insignificant (to you), you have a duty to offer transportation to the hospital. That is your job, after all.

Where there is no medical complaint…
An offer of transportation only serves to protect you. Chances are, if you offer transportation in a situation where there is no patient – as ridiculous as it may seem – they will most certainly decline and you are protected legally because you offered.

No matter what the scenario, patient or not, always document everything.

What did you see, say, do and find? What did they say and do? What did you assess, consider, talk about, introduce and offer? How did they react, respond and reply?

Once you leave the scene, you can never go back; if you didn’t write it, it never happened.

To help further protect yourself when confronted with a non-transport, have the patient acknowledge what you have written and sign accordingly. If there is a patient and non-transport is against your medical advice, document accordingly. Do not have the patient sign the AMA line on the back of your form and finish your documentation later. Instead, have the patient sign beneath your documentation – on scene – as well as the AMA line. If you think this is too much, don’t do it. Being obstinate will cost you, not me.

Also, have a family member, friend or bystander sign as a witness. Better yet, find two. Be sure to collect their contact information as well. If none are available, ask a police officer or fire official. As a very last resort, you may consider having a coworker or your partner sign as a witness, although their credibility in court will be pretty weak.

In any event, when you have your documentation of non-transport attested to by witnesses, you not only ensure that the best interest of the patient is considered and your actions are verified, but you can rest easier knowing that you have done everything to protect the patient and yourself.

As you can see, non-transport can be as treacherous as a critical transport. Be smart, take ACTION and remember that you are the professional.

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