But it’s Just a Broken Nail!

One of the most common topics of debate in this business is something that should be simple. When is it okay for a patient to refuse transport to the hospital?

On the face of it this is a strange dilemma. When is it “okay”? What does that even mean? When is it okay to have Milano cookies and a bottle of Scotch for dinner? I don’t know. Leave me alone.

The chain of reasoning goes something like this. People call 911 because they have problems, and they don’t know how bad those problems are. By and large, we — the EMTs and paramedics on the ambulance — don’t know either. We don’t have the training or the tools to truly rule out major problems. So the only safe thing is to take the patient to the hospital. There, tall men with white coats, eight years of medical training, large expensive machines, and extensive liability insurance can decide if the patient is dying or not.

Okay. In some ways, that makes sense.

In other ways, it’s absurd. We all experience symptoms or incur injuries from time to time, and for the most part, we do not feel the need to visit the hospital to rule out deadly causes. Although it’s always a remote possibility that something is horribly wrong, in most cases it’s extremely unlikely, and it’s senseless to make an emergency out of every ache or sniffle. As we recently discussed, although it is possible to be very sick without looking like it, it is uncommon. If I woke up today with a minor headache, I wouldn’t want to spend hours of my time and hundreds of dollars at the emergency room “just in case.” So why does that suddenly become a reasonable course of action just because an EMS crew is standing in front of me?

There’s one good answer to this, which is that normally, I wouldn’t call 911 for a headache. So if there’s an ambulance here, it already means that for some reason, I had some special concern about this episode. Perhaps it was unusually bad, or prolonged, or I have medical history which makes me worried about what a headache might entail. Alternately, perhaps a friend or family member called on my behalf, but even then, presumably it’s because they had some reason to be worried.

This is all true. People who call for an ambulance are self-selected to be a higher-risk group than the general population. The headache patient who does dial 911 is more likely to be sick than the headache patient who doesn’t.

However, this isn’t always the case, and even when it is, it isn’t always significant. Some patients, or friends and family of patients, have a very low threshold for concern. Sometimes people misinterpret warning signs. Sometimes things just happen. Consider the hundreds of calls we take each year for minor MVCs. Someone dents their fender in traffic, a concerned passerby calls 911, and we show up to evaluate the occupants. There are no noteworthy injuries, and it wasn’t even the people involved who called for us. Is there a chance they have head bleeds, spinal fractures, pulmonary contusions? There’s always a chance. But do they need to go to the hospital? Or, put another way: they didn’t plan on going to the hospital before we arrived. We performed our medical assessment and found nothing alarming. Does the simple fact that we’re here mean there’s any better reason for them to go to the hospital than before we arrived?

Obviously, the answer is no. But we still tend to default to transporting them.

A cynic might suggest that this is because in most areas, ambulance providers can only bill for transports, not for refusals. In fairness, I don’t think this is usually the main reason.

A bigger reason is liability. There is a real concern on the part of providers, and on the part of the services employing us, that anytime we fail to transport a patient to definitive care, we might be “missing” something bad. As a result, they might later sue us for missing this. Would they have a case? Maybe, maybe not; it would depend on whether we followed the standard of care, and whether we implied to them that we “knew” they were okay with any greater certainty than we truly had. That’s the underlying issue, after all. It’s up to the patient whether they want to go, but we are medical professionals, with impressive uniforms and stethoscopes around our necks, and patients are therefore inclined to think that we know things they don’t. They’re inclined to do what we recommend. But even if we think they’re okay, we don’t know they’re okay, so our “recommendation” is usually to see the doctor, because that’s the only truly “safe” choice from our point of view.

Fair enough. But there’s a small problem with this. We’re lying.

Or at least deceiving. We are trained to assess patients, look for abnormalities, and identify findings that point to the possibility of injury or pathology. If we perform this task, and find nothing alarming or even suspicious, we are going to be thinking, “they’re probably okay. I’m not worried.” Why, then, do we turn to the patient and say, “You should really go to the hospital. I’m worried.”? One major national ambulance company has a policy that you should never ask, “Do you want to go to the hospital?” as it implies a choice — but instead, “Which hospital do you want to go to?” Railroading at its finest.

Certainly, it would be just as misleading to tell a patient, “You’re definitely okay.” We don’t know that, because as we already agreed, we lack the training and resources to diagnose anything for sure. But we do have enough tools to make medical decisions, which we do all the time — what’s the best transport destination? which medication is indicated? — and here, too, we can make an analysis of the risk factors. It’s not the same analysis that would be made by a team of doctors with a hospital at their backs, but as long as we don’t pretend that it is, that shouldn’t be a problem.

Think of it this way. If you were in the patient’s situation, would you want to go to the hospital?

Bear in mind that this isn’t a small thing. Depending on your circumstances, this may involve missing work (even losing a job), arrangements needing to be made for babysitting, housesitting, or pet care, cars retrieved, plans cancelled, and oh yes — a bill ranging from a few dollars to many thousands. Can’t pay that? Now your credit is on the line. You can also look forward to hours of sitting on a series of stretchers, wheelchairs, and beds, while busy people wearing scrubs stick sharp things into your flesh, capture your bodily excreta in plastic cups, and ask you an endless series of the same questions over and over and over. You will miss sleep, get behind on projects or errands, and in the end you will have to find a way to get yourself home and clean up from all this chaos. Possibly with a new infection that you picked up in the waiting room.

If we are responsible, we should view transportation to the hospital as a medical intervention in the same category as medications, invasive procedures, and diagnostic tests. It has certain indications and benefits, but also certain risks and harms associated with it, and we should consider both sides in balance before making a recommendation on the best choice. Certainly, that decision will have to be made by the patient, not by us, because it’s the patient who is undergoing these risks and benefits, so it’s they who get to decide how to weigh them. But they also don’t have the medical understanding of the situation that we do. So that’s our job: to transmit to them what we’ve found in our assessment of their complaint. The risk factors, the positive or negative findings on their physical, any alarming vital signs, and the salient features of their history. In many cases, this process is why they called us — because although they’re experiencing something abnormal, they don’t know if they should be worried or not. We won’t have all the answers, but we can give them more information than they had before, and they can use that information to better inform their decision on whether to seek further care. (Remember, this might include scheduling an appointment with their PCP, visiting an urgent care clinic, getting a ride to the ED or driving themselves, and of course the old “wait-and-see” approach. Even when more care is needed, the ambulance isn’t the only answer.)

For the reasons of liability, and policy, and the general fear-mongering attitude that has swept over the healthcare industry in recent years, this is a very difficult line to walk, and in many cases to preserve your job and license you may need to err on the side of “encouraging” a patient to be transported. However, I find it ethically troubling when we mindlessly push everyone towards the ED, no matter what common sense or their medical situation tell us. When we visit someone with a complaint that we’d ignore in ourselves, our partner, or our mother, and convince them to climb into the ambulance anyway, whose best interest are we looking out for?

Are we hurting the patient to help ourselves?

Are we okay with that?

The Tough Ones

People can be pills.

That is, EMS is the business of dealing with people. Even at their best, some homo sapiens will not be your favorite; you’d have to be a saint to love every single person you’ve ever met. And unfortunately, the patients we’re handed in this job are rarely at their best. That’s why they’re in an ambulance. Expecting someone to present a winning smile while they’re dying may be unreasonable.

The trouble is that showing compassion and doing your very best for people is a lot easier when you like them. It’s just human nature; we’re always nicer to the people we identify with, get along with, and find affable and likable.

. . . a lot of ordinary people look totally uncool, especially in their BVDs. In fact, they’re pretty ugly without their clothes on, or at least a little make-up. Some of them are fairly dim bulbs, actually. And on the worst days of their lives, a lot more have BO, bad breath, wrinkles, loose skin, irregular teeth, big bellies, short penises, hair where there shouldn’t be hair, and no hair where there should be. They’re inarticulate, clumsy and, well, kind of ordinary. They don’t match any of those pictures of perfectly proportioned people you’ve seen in your textbooks or on TV.

And guess what? Their families love them dearly, just the way they are!

. . . What you are is a caregiver. What you’re not is a judge. . . . You can be one or the other, but you can’t be both — not at the same time, anyway. As a caregiver, you can’t let yourself slip into the trap of judging people you don’t know anything about, because it does bad things to you. (People Care, 16)

See, the tough thing is that although it’s very human to treat the likable people better, that’s not how this job works. You’re allowed to like whomever you want; that’s your right as a person. But your responsibility as a caregiver is to do your best for all of them, like or loathe. It’s a learned skill, because it’s not at all natural. But it helps if you remember that your standards for likability are far from the ultimate test of someone’s personal worth. Everyone’s fighting their own battles, and patients shouldn’t be expected to look pretty for you in the midst of theirs. You’re not here to add to their burdens.

We have a built-in bias that tells us that people who are smelly or fat or dumb are overall bad people. It’s hard to overcome it. And because people who are choking, or incontinent, or hospitalized tend to be especially rough around the edges, it’s very easy indeed to file them under the category of “unpleasant objects.”

Special mention should be given to patients who are, to put it simply, jerks. Even those of us who can look past physical and mental defects may have trouble treating the world’s biggest asshole like our own dear mother. Once again, we have to remember that we’re not playing this game on a personal level, and the question isn’t whether the patient will be invited to our birthday party. The question’s whether they deserve our best care — and whether or not that’s difficult, whether or not we want to give it, the answer is “yes.” That’s how this works. If they’re a patient, they get our best. Some nasty physical ailments are harder to treat than others; some personalities are likewise harder to tolerate. But we don’t get to pick and choose, so we just have to suck it up and be compassionate professionals across the board.

Try to develop the mindset that to be human carries an inherent sacredness, value, and dignity. And that even the most despicable and worn-out creature on your stretcher has the same needs and feelings, and likely the same sense of self-worth, as any CEO or socialite. To quote Antoine de Saint-Exupéry, “I have no right to say or do anything that diminishes a man in his own eyes. What matters is not what I think of him, but what he thinks of himself. Hurting a man in his dignity is a crime.” (From How to Win Friends and Influence People, 214.)

All of this isn’t easy. Striving toward it is a constant effort. But if you can take a patient who you truly loathe, and treat him just the same as you would your own child — or your partner — or yourself — then that’s something to celebrate. Because quite frankly, the patient is somebody’s child, or somebody’s partner, and odds are good that their opinions of his human worth may differ from yours.

. . . until the curtain was rung down on the last act of the drama (and it might have no last act!) he wished the intellectual cripples and the moral hunchbacks not to be jeered at; perhaps they might turn out to be the heroes of the play. (George Santayana on William James [from Linda Simon’s William James Remembered])

Patient Advocacy

What does it mean to be a patient advocate?

I first learned this term from my original EMT textbook, and since then, it seems like it’s been the favorite buzzword of the medical profession. It’s a little bit like “leveraging synergies”; it sounds surely good while having no clear meaning at all.

I think this is a shame, because to me, patient advocacy is actually a very meaningful concept, and in EMS, a very important one. Perhaps this isn’t true for doctors and nurses, radiologists and cath technicians — although I’d like to think it is — but on the ambulance, it’s more than just a pretty ideal.

This was what the textbook had to say:

As an EMT-B, you are there for your patient. You are an advocate, the person who speaks up for your patient and pleads his cause. It is your responsibility to address the patient’s needs and to bring any of his concerns to the attention of the hospital staff. You will have developed a rapport with the patient during your brief but very important time together, a rapport that gives you an understanding of his condition and needs. As an advocate, you will do your best to transmit this knowledge in order to help the patient continue through the EMS and hospital system. In your role as an advocate you may perform a task as important as reporting information that will enable the hospital staff to save the patient’s life — or as simple as making sure a relative of the patient is notified. Acts that may seem minor to you may often provide major comfort to your patient. (Limmer 11)

Not half bad, really. But raise your hand if your eyes glossed over that paragraph.

You see, as a prehospital provider, you occupy a unique role in a patient’s course of care. Your time with this patient, from initial contact until transfer of care, is one of the only periods when they’ll have the one-on-one, undivided attention of a healthcare provider. Think about that for a moment. Ms. Smith may previously be, or soon will be, under the auspices of a veritable pantheon of specialists — cardiologists, endocrinologists, orthopedists, neurologists, and more. On this occasion alone, she might pass through the hands of an ED physician who stabilizes her, an internist who admits her, a surgeon who operates on her — never mind a supporting battalion of nurses, techs, CNAs, therapists, and witch doctors. It takes an army to treat a patient.

But that army has other responsibilities, too. That ED doc has two dozen other patients screaming for his attention, most of whom have already been waiting for hours. The internist is running a code in the next bed. Those nurses are overworked, underpaid, and really want to get home.

As a rule, they all have the best intentions, and they all want to look out for the patient. True bad apples or apathetic mercenaries are a rarity in this business. But everyone’s simply spread thin. Even when they have the resources to give their undivided attention to an individual patient, it’s rarely their responsibility to do so. The cardiologist is here to provide a consultation on Ms. Smith’s heart — not to champion her care like the Hospitalist Prince of North 6 and butt into everyone’s else’s work. It’s just not his job.

But what about you, the humble stretcher monkey who brings her in? For that brief period of time, you really have no business except Ms. Smith’s well being. That’s why you’re here; that’s what you were dispatched to look after; and it’s your legal, medical, and moral responsibility to do everything you can for her, until such time as you transfer that responsibility into the aforementioned healthcare cloud (or she refuses further care). Assuredly, you have a defined scope of practice, and company policies to follow, but we’re not talking about cutting out her gallbladder or taking her to a dive bar. We’re talking about — say it with me — patient advocacy. And everyone upstairs agrees that’s part of your job.

Your job is to be her champion. Not because you’re Superman. But because she’s so vulnerable right now, she doesn’t need Superman; she just needs anyone who will step up. Anybody who’ll stand there and say, you are not alone. We all need that, and we all deserve it — but many of these patients, after countless years and battles, have no one else to turn to.

Let’s steal a quote — this is from Danielle E. Sucher at Legal Agility, responding to the question of why she practices criminal defense.

I don’t like hurting people. Is that so hard to understand? When I go to bed at night, I can sleep easily, knowing that I fought for freedom, and for less suffering rather than more. That I stood by someone accused so that he would not have to stand alone.

I can’t know whether anyone is truly guilty or innocent, or what they deserve, and frankly, I don’t care. We all deserve at least one person on the damn planet willing to stand there next to us and fight on our behalf.


Patients have problems. You can’t help with all of them. You can’t cure their cancer, or pay their bills, or make the world fair and right. But you can do an awful damned lot, because it’s astonishing how large the gap is between what the patient would do and what they can do in their current, largely powerless position.

You have resources. One’s this big ambulance, and everything in it. But you also have the resource of knowledge: you know how the system works. You know where to go for certain things, you know who to contact to get what you need, and you know what’s available for the asking. These would serve you very well if you should need to visit the emergency room or become hospitalized, or if your mother should, or your child. If Ms. Smith were your mother, you wouldn’t just shuffle through the process of putting Person A into Slot B, ignoring her needs and looking for ways to avoid going the extra mile; you’d fight like hell to keep her as happy, as comfortable, and as looked-after as possible. Because patients can’t fight for themselves, any better than defendants can argue their own cases. And because although other professionals will be involved in this process, they won’t be fighting for the patient either. I have immense respect for the docs and the nurses, but sometimes, you’re standing in a place to do things they can’t. A few of them may go above and beyond, but they all have their jobs to do, and this isn’t it.

But it is yours.

Good Partners

EMS today is almost invariably practiced in two-person teams.

The main exception to this is in the fire service, which — even when called in an EMS role — is often built up from crews of three or more. And on 911 calls in many areas, ambulances are routinely dispatched alongside the fire department and sometimes police or other resources, so it’s not unusual to see a half-dozen responders or more on a scene.

Nevertheless, this job is fundamentally one that you perform alongside one other person, and that environment defines how we live and work. In fact, the dynamic between you and your partner can come to resemble the relationship of a married couple, an observation made by many a poor spouse after realizing their significant other spends more time with a mustachioed paramedic than with them.

You spend upwards of 10 hours a day sitting in a small box with this individual, talking to them, listening to them, and sharing all their favorite habits, odors, and bodily noises. You experience the best of their personality, but also their worst, and you learn what they listen to, who they hate, and how they address and solve their problems. To do your respective jobs, you’ll have to find ways to compromise where you don’t agree, adhering to what you think is right but ultimately doing what’s necessary in order to get the task done.

We all hope to work with a good partner when we check the schedule, but what is it that makes for a good partner — how can we be that person to someone else? There are many qualities, and some (such as personality) are heavily subjective, but one I think is universal.

Good partners are reliable. This is a word that doesn’t get much respect nowadays — reliable is boring, 8-track tape and grayscale television, reliable is what your grandparents and Dick Van Dyke were. Certainly, although intellectually we acknowledge that it’s a good thing, “reliable” may not exactly be the byword we’d want on our EMS tombstones.

But reliability is a funny thing. Like good life insurance, it’s something nobody wants, but that we all want in the people around us.

Not everyone works this way, but I have a simple system when working on a dual-EMT crew. On any given call, one person drives, one person techs. If I’m the tech, I’m in charge of the call: I do all the history-taking and communicating with the patient; I give and receive the reports; I make the decisions about next steps and the course of care; I stay by the patient’s side from start to finish, and in the end I’ll write up the documentation. As for the driver, he obviously is responsible for driving, getting us from Point A to B and later to C, and related tasks like the radio; but most of all, his job is to help me out. Record vitals, retrieve equipment, start interventions, take heat — whatever is necessary to free me to do what I need to do.

It’s the job of the tech to keep the entire situation in perspective and paint the path that will, when viewed in retrospect, be clearly visible as the ideal course of care given the patient’s complaint. But many obstacles may interfere with that path, and the more that my partner can help clear those away without a hiccup or hesitation, the more smoothly things will go. This means doing what I ask without question, or better yet, anticipating it even before I ask; it means seeing and foreseeing problems and knowing how to pave them over without diverting us from our primary goals. I can be somewhat anal about this division of responsibility, not because I’m a control freak — I’m happy to play the other part when my turn comes — but because the best way to drop the ball and fumble through a run is by having two chiefs and no indians. Although there are times for collaborative discussion, and times to throw up your hands and refuse to do something foolish, the majority of actions and decisions on any given call are simply things that need to be performed by someone, rather than tabled for debate by committee.

Here’s where the issue of reliability comes in. As a crew, we have the potential to do some wonderful things, including pushing boundaries and getting creative in ways that are anything but boring. But in order for me to go out on a limb, I need to know that you are going to be able to back me up — cover your end of the show, pick up the slack and fend off any looming hazards. If I can’t rely on that, then I can’t extend myself, because I’ll need to hold something in reserve to pick up whatever you drop. If you don’t know how to get us to the hospital, then I may not be able to accomplish very much in the back, because I’ll need to divide myself between the patient and helping you navigate. If I need to ask questions, read meds, take vitals, and package the patient all at once, don’t be surprised if only half as much gets done, because I’ll be doing the work of two. I may be able to handle a rough call with the most useless partner in the world, but it’ll be done in the most bare-bones fashion, merely trying to get through it without any disasters and struggling to hold our heads above the standard of care. However, if you manage your end of things seamlessly and effectively, that frees me to step everything up; the more you can do, the more I can do. Reliability is boring if it’s all there is, but when it’s the immutable backdrop of your care, it’s actually the foundation for all creativity and excellence.

(Now, there are crews out there who don’t work this way. Instead, they handle things cooperatively, each member doing what needs to be done and nobody in charge. This works best when they’re very experienced and familiar with each other, in agreement on most decisions and practiced at staying mutually out from underfoot and functioning synergistically. This is not common. However, the important thing is that even on a crew like this, reliability is all the more important, because it has to run both ways — if we each have equal opportunity to drop the ball, then we each have to be absolutely reliable.)

There’s a major interpersonal element to all this, which is trust. Trust is the coin you pay back for reliability. I need to be able to trust my driver to do his job, and likewise he needs to be able to trust that I’m making smart decisions. If I’m sitting in back and tell him to hit the lights and divert to a nearer hospital, I need to be able to trust him to get us there safely and quickly, otherwise I’ll be forced to take time from the patient to monitor and direct him. But he also needs to trust that I’m making an intelligent decision based on a sound assessment, because he doesn’t know what’s going on back here either, and I may not have time to explain. How bizarre of a request can I make without him balking or refusing? That depends; how much does he trust me?

Just like in a personal relationship, the fear of lending this trust comes from a legitimate aversion to risk. Although trust in an intimate relationships puts us at risk of emotional harm, trust on this job places our career and the lives of our patients and ourselves on the line.

If I was wrong to trust my driver, he might get lost, panic, plow through an active intersection and kill us all. Of course, if he was wrong to trust me, our patient might receive the wrong care, die in a trauma room somewhere, and we’ll both be fired and stripped of our certifications. Extreme, but possible. In many jurisdictions including my own, both members of a crew are held equally responsible for all aspects of patient care; this fact alone makes trust tremendously important if we’re ever to divide up responsibilities at all.

For this reason, I feel that trust has to extend to before and after the call as well. Everyone has heard these rules, and everyone has broken them. “What happens on the truck, stays on the truck” is a popular one, mainly because we’ve all confided something to a partner only to hear them later repeat it to the wrong person — either innocently or seditiously. This sort of thing is fertile grounds for drama, which is no fun, but what’s key is that trust isn’t compartmentalized, and if you can’t trust your partner in a personal capacity, you won’t trust him professionally either.

I recommend these basic rules:

  1. Never relate any personal information told to you by your partner, unless you either request permission first, or “HIPAAfy” it so it can’t be linked to him (“one of my partners was telling me…”).
  2. Never tell any stories that could paint a past partner in a bad light, unless you either request permission or HIPAAfy it.
  3. Never involve supervisors or management staff in personal or operational problems, unless critical and intractable patient care issues are concerned.

These are pretty simple rules to understand, although harder to consistently apply, because we’re all blabbermouths at heart and don’t realize when something innocuous to us is private and personal to someone else. The gist is simply that there is a bond of trust between your partner and yourself, regardless of whether they’re a close friend, a hated enemy, or a total stranger; and that bond should not be violated except in extreme circumstances, generally involving the safety of yourself or others. Even in cases like that, every effort should be made to resolve the situation without violating their trust, which isn’t always the easiest method, but it is the best for everyone involved.

Again, this serves to reduce drama and maintain personal relationships, but we’re talking about it because it directly impacts your work. You must be able to trust your partner, or you will be a dysfunctional crew. (If I know you can’t be relied on, I can’t trust this blood pressure you took, can I?) Moreover, you will never be able to help your patients in any but the tightest, most minimal and conservative way, because you don’t know if anything else won’t come back to bite you. You’ll move through your day tense and fearful of being under the eye of someone you don’t trust. Bad news all around.

I’m not suggesting that these ideas are easy, because they aren’t, and dealing with their results and fallout is what makes up a lot of our daily troubles. But this is a team sport, and it can’t be done right any other way.