Best Practices: Handling "Non-Patients"

As an academic emergency physician and an EMS Medical Director who also functions as a field provider, I strive to deliver medical care that is based upon scientific evidence or at least what is considered "best practice" in the absence of clear-cut proof of efficacy. Contrastingly, over the years I have found many daily practices of out-of-hospital clinicians to be based largely on myth and/or non-evidence based medicine handed down from one generation to another in EMS. Furthermore, my observation has been that many prehospital providers allow peer interaction to drive such clinical decisions rather than proven and accepted concepts of emergency medicine and/or principles of health care law. In some cases, the care rendered to the public based upon "this is the way we do it" guidelines is inappropriate and in other cases it is downright dangerous. All jokes aside, there are numerous examples of hand-me-down out-of-hospital care tactics that constitute what may be titled EMS "worst practices." The goal of this column is to present what is often called "best practices" or a generally agreed upon method to approach a clinical condition.

Question: What is the recommended procedure to handle persons involved in a vehicle crash who claim not to be patients?

Best Practice: Make a reasonable attempt to determine whether or not every person who is involved in a vehicle crash has been injured. This may require the EMS provider to ascertain whether or not an individual has the capacity to determine injury or requires information from EMS in order to make an informed decision about acceptance of treatment and/or transport. Whenever possible, the EMS provider should obtain an informed refusal, which by definition requires documentation and a signature or attestation on the part of the patient who is refusing treatment and/or transport, that this individual does not want emergency medical services intervention. How to document the fact that individuals do not want to be declared a patient, since there would then be no patient care report, remains a vexing issue and one which your agency supervisor and medical director should address in an SOP.

I have had several requests from the readership of EMSResponder.com to write about this subject matter. The problem of how to handle the "no patient" incident at the scene of a vehicle crash has troubled many EMS providers over the years. I, myself, encounter this issue several times a year when I staff an ALS ambulance crew in the Philadelphia suburbs.

The approach to this situation should be fairly conservative to avoid the possibility that truly injured patients are left at the scene. Such action invites the specter of abandonment if a seriously injured person actually requires EMS and this fact is ignored or missed unintentionally. Second, we have all returned to a crash scene at least once in our careers for the person who decides 10-20 minutes after the ambulance leaves that he/she now wants transport to a hospital. Obviously, this behavior leads to decreased unit availability and unnecessary lights and siren use back to the scene. It can also stir up ill feelings on the part of the EMS providers which are aimed at the patient and this type of behavior generally does not lead to productive patient relationships.

Of course, a vehicle crash is not the only scenario in which an individual who could possibly be a patient has declined such status. However, vehicle crashes are very common and involve some factors which make the no-patient scenario more complicated. Thus, it serves our purpose well.

Before, I list in sequence how I approach this scenario, I should address the speeding train coming at me which represents all the urban EMS providers who work in systems where they run 2-3 calls per hour all day long and barely have time to breathe, let alone time to give a speech to "non-patients" at a crash scene or write a dissertation about why someone does not want EMS transport. I was the EMS and Disaster Medicine fellow in Washington, DC for two years in the mid-1990s and in that role functioned as the Assistant Medical Director for the DC Fire and EMS Department. I spent quite a bit of time in the field riding with ambulance crews, EMS supervisors and responding from home to high profile incidents to provide direct medical oversight or to be part of the incident management system. I know first-hand what an over-worked and underfunded EMS system looks like and how difficult life can be for the street medic or EMT who gets pounded into the ground on a daily basis. I have also had paramedics work for me whose primary job was in a city fire department and I have daily interactions with Philadelphia Fire Department Paramedics who remind me constantly how my stress levels do not compare to theirs (and they are right!). Despite the fact that I understand why the there may be less documentation or patient discussion in urban EMS agencies, I am still obligated to present what I believe to be the best practice for this situation.

What is listed below is an approach that will work for the average suburban or rural EMS system in which there are either adequate resources to handle the call volume or few calls to make one worry about spending an extra 10 minutes on scene or at the station documenting a trip sheet. I will be the first to tell you that much of what is listed below is not feasible in many urban EMS systems due to call backlog, manpower constraints and other logistical factors including interactions with law enforcement. Therefore, I preface my comments with the opinion that I feel your pain in the inner city and understand why what is printed below does not happen routinely in busy EMS systems.

Step One: Response to the Scene

There are three possibilities that come to mind when dealing with the response phase of the "no-patient" vehicle crash. First, the responding ambulance crew is recalled prior to arrival at the scene by another public safety agency (PSA) officially dispatched to that scene. An ambulance crew which is officially recalled by an AHJ agency prior to arriving at the scene has no legal responsibility to verify that there are no patients at the scene.

Second, the ambulance crew is recalled by some individual who represents or claims to represent a PSA who happens upon the scene. There is a distinctive difference between the two situations here. In most EMS systems any PSA within the authority having jurisdiction (AHJ) can recall an ambulance if there are no patients at the scene. However, volunteer or off duty law enforcement, EMS or Fire personnel who do not officially represent the AHJ should never make this call since there will be no paper trail to document the decision-making process, patient discussion or the final outcome of this incident.

Third, the ambulance is recalled as it arrives at the scene. Once the ambulance arrives at the scene, the crew has a legal obligation to evaluate any potential patients assuming that the first responders have not already executed an official patient evaluation and/or refusal of care, which may happen in systems in which paramedic engine/ladder companies arrive at the scene and private ambulance contractors arrive afterwards. Care should be exercised when the ambulance crew has a higher level of training that the first responder company, but that company tells the crew not to worry about leaving the scene without patient evaluation. Failure to do so may constitute abandonment and negligence concerning the duty to act. My rule is to thank the police department or first responder company for their information and proceed to directly interview the potential patients myself in concert with my partner.

Step Two: Scene Assessment and Determination of "Patient" Status

Let us assume that the scene is safe, hazards have been mitigated, and that in short order we find a 50-year-old male who does not claim to be a patient. My partner and I approach every individual who has been involved in the crash. How you converse with victims at the scene of a vehicle crash or any other incident is critical to its outcome. I ask each person whether or not he/she believes themselves to be injured. However, I do not stop there. If the person states that he/she is not injured, I ask their permission to perform a focused physical exam and to acquire vital signs so that I may provide information that may help shed light on any possible injury or acute medical condition. Why do this?

It is quite possible that many persons who could be injured do not realize this fact. After all, not everyone experiences pain the same way and not all injuries carry with them immediate pain. Diabetic patients may have altered pain receptors. Sometimes a distracting injury may exist for which the person does not want to seek health care but this pain causes the person to disregard a potentially more serious condition. Others do not want to admit pain or injuries for a variety of reasons, including concerns about cost of health care, fault of the crash, separation from family members or because of lack of understanding of English. As patient advocates, it is our responsibility to do whatever possible to provide emergency health care for individuals who present to us through the 911 system.

If the individual whom I have asked to permit me to examine them says "yes," I obtain a full set of vital signs and conduct a physical exam to determine presence of injury. When transport is refused, this patient contact becomes a "refusal of care." If the person refuses even examination to determine injury or possible abnormalities in vital signs, I move to the next point in the decision algorithm: Does this person have the mental capacity and the legal capacity to make such a decision? In the majority of cases when dealing with an adult who does not appear to be injured, the answer is "yes." However, minors and those who are mentally incapacitated from alcohol or a head injury may not be competent to refuse care. This discussion is beyond the range of our subject matter this month. Thus, for purposes of this column we will assume that the individual is competent to refuse evaluation.

My next move is to confront the person in a friendly and professional manner and inform him that the responsibility of EMS is to offer everybody at the scene the opportunity to be examined so that we do not miss any injuries. If he refuses this gesture and there is no obvious injury or evidence from the crash scene that suggests that the individual may be at risk for significant injury, I declare him a "non-patient" and the interview is over.

If I feel strongly that the person should be evaluated in an emergency department, I attempt to coerce the person to accept evaluation and/or transport by having family or friends at the scene apply pressure, pointing out significant damage to the vehicle (if that is the case), describing how pain and injuries often become apparent within one hour after the crash and by informing the person that vehicle insurance covers most medical costs, even if that person is not the one who has insurance. Finally, I invoke the guilt factor. I inform that individual that my job is to take care of their health and that he is impeding me from doing my job properly. If he still refuses, he becomes a "non-patient."

Step Three: Documentation of the "Non-patient" Incident

Several questions arise from the scenarios above. Where is the line drawn between a "non-patient" and a patient who refuses care against medical advice and who refuses to sign the refusal form or to provide any demographic information? How is a motor vehicle crash documented where an individual declares themselves a "non-patient" since all patient care reports are based upon the concept that there is either some demographic information available or that there is an unknown patient who has a medical chart written about him?

Common sense should guide one in the majority of these circumstances. Persons who are obviously injured and refuse evaluation or transport are considered to have refused care against medical advice whether they have signed the refusal signature or not. Obviously, failure to sign and the reasons provided for doing so must be documented. These charts require meticulous documentation since historically non-transports have accounted for a large percentage of EMS litigation.

For those individuals who are non-patients, I document their situation in one of two ways. If I write "no EMS required," my chart reflects that there were individuals involved in the incident that did not want to declare themselves as patients. Alternatively, I write an incident report and describe the persons as best as possible (young male driver of green car) next to the statement that says they refused examination. I also make sure to inform the police officer who is writing up the primary report about the collision that the persons declared themselves as "non-patients." This way there is added documentation that this is actually the way events unfolded should the incident ever be revisited in court.

If you know of an EMS practice which is questionable, hotly debated amongst your fellow providers or downright dangerous, e-mail me at jaslowd@einstein.edu with your thoughts and what you think is the standard of care and we will discuss it in this open forum. Hopefully, we can improve care through education.

Dr. Jaslow is a board certified emergency medicine physician fellowship-trained in EMS and Disaster Medicine. He is the Chief of the Division of EMS, Operational Public Health and Disaster Medicine and Co-Medical Director of the Center for Special Operations Training within the Department of Emergency Medicine at the Albert Einstein Medical Center in Philadelphia. Dr. Jaslow is also the Medical Director and Lead Physician for the Pennsylvania Task Force-1 Urban Search and Rescue Team and an active firefighter/paramedic and EMS Medical Director in suburban Philadelphia. He currently serves as the Medical Editorial Consultant for EMS Magazine and as a member of the editorial board for Advanced Rescue Technology. He can be reached at jaslowd@einstein.edu.