Friday, August 01, 2008

To AMA or Not to AMA. This is the question.

Ok, we have all got those calls at 4am that you just know are bull-shit. You arrive on scene and find lots more drama than trauma. You know they don't have any serious problem... or do you?

Today I had one that was kind of strange as far as possible AMA's go. You see, I don't talk a patient out of going to the hospital ever. I always felt it was my job to talk them into going to the hospital. After all, they did call 911; I would like to think I was there for a reason.

50is woman in a praying position on the floor with arms holding her up against the side of a night table. I stated "Mam, I'm here with EMS, can you tell me if you hurt anywhere?" She replied very slowly: "No I don't hurt but my legs and feet are asleep, I've been down here 3 hours."

After a brief assessment myself, my partner and the FNG helped her to her feet and she could not bear any weight (This lady was 400lbs +). We sat her down on the edge of the bed and began to sort through the laundry list of medications and diagnoses she had. All of which are not really important at this time.

After assessing her again sitting this time I noticed that she was answering everything correctly but it was taking her forever + 1 day to do it. She was incontinent as well... So I'm thinking seizure or stroke right? She is flat out refusing to go to the ER. She states they wont do anything for her. We run baselines and check a sugar... 320. Ouch, that sucks... now I'm thinking DKA or Hyperosmolar NKA (Medic school taught me big words).

The only person there to help her is her 75 year old mother, and there is NO WAY IN HELL she would be able to help her to the bathroom or to get a shower. I call the doctor hoping he will mandate her. No Dice. He told me that if the patient was A&O he wasn't going to mandate her to be brought in.

So here I am with this problem. I know she needs to go, my partner knows she needs to go...hell even the FNG knows she needs to go, but she refuses to go.

Finally I leveled with her. I told her that I was not comfortable with her being by herself and I knew that her mother could not get her cleaned up or even up to go to the bathroom. She nodded. Then I gave her the option of agreeing to go to the hospital with me or I was going to be forced to call the social services officer to place her in protective custody.

After a few minutes of word wrestling and a couple unflattering comments made under her breath she agreed to go.

There really is no moral to this story, but consider what could have happened to her if I would have just happily had her sign the AMA form and left. What would have my responsibility been then?

Food for thought: Have you ever signed off someone only to have it come back and bite you in the ass? Let me know.



Anonymous said...

I have been faced with the exact same situation you recently had. I work for a service that handles Emergency Response for approx 800,000 people.

I was faced with a woman that flat out refused to go to the hospital with us. Her O2 sat was literally 50% on R.A. Per the family she had period of syncope and thats when they called us. The patient was A&O and was adimantly refusing to go to the hospital. She was advised that her Vital Signs were abnormal, and that only a doctor could medically clear her. She stated I am fine, I will see my doctor in the morning. We had her family contacted and they attemptd to persuade her to be seen at the hospital. She still refused. We even contacted Med Control on a recorded line and they told her she needed to be seen at the hospital. She still refused. No Law Enforcement Agency is going to EOD this patient due to her mental status and her right as an adult to refuse treatment. She signed a refusal form AMA.

Approx 1 hour later we were called back and she was in Cardiac Arrest. She ended up dying.

I did not feel like I was liable for the patient making a huge judgement error. I documented everything that happened and what steps the EMS crew took to encourage her to be seen.

I have never heard anything else from this call, and I believe the statute of limitiatons has been reached as well.

I have spoken with a lawyer and they stated that as long as the patient is A&O and competent to make medical decisions and you advise them of all the risks, and they sign a refusal form......EMS Provider liability is then gone.

Anonymous said...

I am a current EMT-B student. I am able to ride along on calls with our volunteer rescue squad and recently responded to a rollover accident call. When we arrived on scene, the woman driving the SUV that rolled over was already walking way down the street where two passersby had pulled over to help. The woman claimed to be unhurt and fine and didn't want us to check her out. Our Fire Chief got into a screaming match with her about how she is being stupid and needed us to at least talk to her inside the ambulance. He, however, managed to confince her to at least have us take some vitals inside the ambulance. Looking at her vehicle I couldn't imagine her not being hurt in any way, but she insisted she didn't want to have to pay the ambulance bill and that she couldn't afford to be transported. We noticed some alcohol on her breath and indicated this to the sheriff deputies on-site. They, however, didn't really seem to care about it. They almost seemed to have the attitude that since she didn't not have any impact with any other vehicles that they had no reason to give her a breathalizer test. I was very confused by it all. She signed an AMA form and refused any further transport/treatment. Could this not have been a reason for us to claim her incompetent due to the alcohol she had consumed, therefore have a reason to transport her? I later found out that the deputies even gave her a ride back home - which I didn't think was possible. I guess I left that call more confused than ever. I felt the deputies did not act properly and I also felt our rescue squad members did not really care to push the deputies to do their job. It was almost as if everyone just wanted to get home that night and get it all overwith faster. Was I wrong to think that everything did not seem to be "up to par"?