How Do You Decide Who Is an EMS Patient?

How Do First Responders Decide Who's a Patient?

paramedic with patient
Judith Haeusler / Getty Images

In a hospital or a doctor's office, it's easy for caregivers to tell the difference between the patients and family members; they tell you. Patients come to the reception area and register as a patient. Patients get armbands that have to be scanned and double-checked every time a healthcare provider is going to provide some healthcare. Often, visitors or family also register and even receive a badge or a label to let everyone know that they're not patients.

The identification of patients in most healthcare settings is so intuitive that to define a patient in these facilities does not even cross the minds of the caregivers who work there. Identifying the correct patient, on the other hand, is a bigger deal. We want to make sure that we don't administer a drug or perform a surgery on the wrong person. Nurses and doctors in hospitals have a bit of anxiety over the possibility of the wrong person wheeling into a procedure room unnoticed. The idea that the person might not even be a patient at all, however, isn't even a consideration.

Patients Outside the Hospital

It's different for a first responder. Patients are not as easily identified. There are certainly the straight forward cases: A person has pain and calls 911. Paramedics arrive to find a person complaining of pain and asking when he's going to be on his way to the hospital. There's no doubt about who the patient is when first responders arrive.

It's not always that clear. What if the person you thought was the patient didn't actually initiate the response. Here's an example: You are visiting your elderly mother and she tells you that she hasn't been feeling well lately. You see that she is moving slowly and appears to be in pain. She winces when she stands or sits.

She seems a little pale. You decide she looks really sick and you call for help.

To Seek or Not To Seek

When firefighters arrive at your mother's home, she tells them she didn't really want any help. She refuses to comply with their physical assessment and doesn't really answer their questions. When the ambulance arrives, she refuses transport to the hospital.

Is your mother a patient? That's a tough call. She didn't seek medical care, which is the way most healthcare facilities identify their patients—by the very fact that the patient sought help. She refused their help when they arrived and she didn't participate in her own care. This is her home, not a hospital. She wasn't a patient before you called 911, and she didn't call.

If you're the first responder on this run, what do you think? Someone was concerned enough to call for help and would like you to assess the "patient" for a possible medical problem. It's true that the person is refusing care, but it's also true that heart attacks or septic infections can be very subtle, even to the person who is sick. Should the first responders pack up and head back to the station or insist that your mother sign a form stating that she is refusing care against medical advice?

Too Many to Count

What if you're a paramedic working on an ambulance and you're sent to a vehicle accident involving a crowded bus? The bus struck another vehicle at a pretty slow speed. Nobody is seriously injured. There is a person on the bus who was standing at the time and was knocked to the floor. He wants to be seen by a doctor at the hospital. Everyone else on the bus wants to get back on the road and would kindly like you to get out of the way.

Is everyone on the bus a patient? Most have expressed a desire not to be evaluated, but they all did suffer a mechanism of injury significant enough to cause at least one person to be seen.

They were all passengers in a vehicle involved in a collision. Are they all sober? Someone called 911, possibly even from the same bus. Should first responders bring in a battalion of helpers to evaluate and discuss informed consent (or informed refusal) to everyone on the bus before allowing the driver to resume her route?

These are tough questions for first responders, especially in the United States. Many states allow first responders to be sued for negligence or abandonment if they leave a potentially injured or sick patient behind without proper care. Healthcare case law is largely built on doctors and nurses practicing in a facility setting. What is based on emergency medical services is pretty thin and often doesn't cover the myriad complicated scenarios that paramedics face almost daily.

Who Pays?

Also, an American problem is cost. Without the universal healthcare enjoyed by many other industrialized nations, patients in the United States often have to pay for their care out of pocket. Some areas only charge if the patient is transported to the hospital, but plenty of places charge to assess patients in the field, regardless of what, if any, treatment was provided.

If Mom turns out to refuse all care and not to be transported to the hospital, is it fair to send her a bill for the assessment that was provided? Someone called 911 for her because she appeared to be in need. Highly trained and competent healthcare providers responded and provided an initial assessment, which would have resulted in potentially life-saving treatment had she presented in a more severe way. However, she still didn't seek her own care, so should she be responsible for the cost?

Err on the Side of Caution

When faced with this situation, the paramedic's best option is to consider the goals of the interaction with your mother. The paramedic wants to provide good medical care without encroaching on the rights of the individual. How is that best served? Leave the question of cost out of it for now, because the answer to what should be done clinically and what should be done financially are not always aligned, and make the scenario unduly complicated.

A minimal assessment can be done quite passively. Skin signs, especially color and moisture, can be ascertained without physical contact. Movement, appropriate responses to questions, steadiness—all can be observed from across the room. If the subject of the call to 911 (specifically not calling her a patient) appears to be in medical distress, it would certainly behoove the responders to tread carefully. Full and complete documentation is essential. She should be treated like a patient in documentation, even if she denies the category. Recording everything is important both legally and clinically. If, indeed, there is a medical problem that progresses, observations made by the initial first responders could help with an eventual diagnosis, even if no treatment is done during the first interaction.

The case of the bus is more difficult. The mechanism of injury is certainly present and there is a decent argument that a crash significant enough to cause injury to one occupant has the potential for causing injury to others. Unfortunately, it's a slippery slope. Responders find themselves at the mercy of those at the scene to help them identify true patients when multiple people are involved. The safest position from a litigious point of view is to treat everyone on the bus as potential patients and make all of them sign forms refusing care. In most EMS systems, there is not a method for abbreviated documentation to help with the overwhelming case load that would create.

Unfortunately, there's no great way to easily identify patients in the prehospital setting. There is a strong reliance on caregiver intuition and circumstances. Keeping the potential patient's medical care foremost in mind, the most important thing to remember is that some people don't seek medical care until it's too late.

Sources:

Evans K, Warner J, Jackson E. How much do emergency healthcare workers know about capacity and consent? Emerg Med J. 2007 Jun;24(6):391-3.

Moore, G., Moffett, P., Fider, C., & Moore, M. (2014). What Emergency Physicians Should Know About Informed Consent: Legal Scenarios, Cases, and Caveats. Academic Emergency Medicine21(8), 922-927. doi:10.1111/acem.12429

Continue Reading