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Case Studies in EMS Medical Control
By Bernard Heilicser, DO, MS, FACEP, FACOEP, Medical Director, South Cook County EMS System; Director, Medical Ethics Program, Ingalls Hospital, Harvey, IL.
A 50-year-old female called emergency medical services (EMS) because she is short of breath. She has a recent history of pneumonia and received outpatient treatment. The paramedics arrive and find the patient in moderate respiratory distress. The patient states she wants to be transported to Our Lady of the Financially Secure Hospital (Hospital A) because this is where her health maintenance organization (HMO) is; the estimated time of arrival (ETA) would be 15 minutes. Medical control directs them to go to the closest facility, Destitute Medical Center (Hospital B), with an ETA of 3 minutes. The patient adamantly refuses and states she will refuse treatment rather than be transported to the directed hospital. What would be the appropriate action by EMS?
The Importance of Medical Control in EMS
Medical control is a function in emergency medicine that is often underappreciated and relegated to a "radio nurse." Different systems have different approaches to the direction of an EMS provider, whether it be simple subjective oversight of an EMS call, or specific point-by-point direction. The assigned individual who takes the radio call may be an emergency department (ED) tech, a nurse or a physician. Regardless, who has the ultimate on-line responsibility for that call? The ED physician does, whether in the radio room or not.
Consequently, decisions affecting patient care by EMS can have very significant medical legal impact on the on duty ED physician. (The off-duty medical director has 24/7 responsibility, but cannot control every call).
Patient Refusing Direction from Medical Control
So, we have a patient in moderate respiratory distress who will not abide by medical control. What should EMS do, and what should medical control do to help resolve this situation?
The patient has stated she will not go to Hospital B. Can she refuse? This would first bring into play her decision-making capacity. In general, patients who demonstrate decision-making capacity can refuse medical care. Although decision-making capacity is more a medical determination than a legal decision, legal principles would ask if the patient understands their condition / situation, and do they appreciate the choices?
Informed consent / refusal typically involves the patient being aware of the consequences of their actions and having been given the risks and benefits. These situations are state-law-specific. We tend to disregard patients' autonomous requests when they are not in agreement with what we perceive to be in their best interest. Physicians do this at their own jeopardy, because patients have the legal right to accept or reject treatment.1 Rumor has it that we also divert ambulances to help decompress a crowded ED. This patient is in moderate respiratory distress, but she was capable of discriminating the potential financial ramifications of hospital destination. EMS calls back to medical control and reiterates their concern. Medical control states the patient cannot go to Hospital A, and should then sign a refusal on the EMS run sheet and be allowed to fend for herself. True, the patient has demonstrated decision-making capacity and was given the opportunity for informed refusal, thereby giving protection to the EMS providers and the hospital.2 However, is this in her best interest?
What have we accomplished? The patient will now call a taxi, go by private car, or just stay home. Is it preferable that this patient present to Hospital A by these means or by ambulance? Cardiopulmonary resuscitation (CPR) in a taxi would not bode well. If Hospital A was on bypass / diversion, would this change the approach? With a formal policy addressing diversion, protection may be afforded.3
Medical control needs to be flexible and handle each EMS call on a case-by-case basis. Ultimately, the question is, "What would be in the patient's best interest in the context of potential harm?" Likely, CPR in an ambulance rather than in a taxi.
Should a Spouse Dictate Transport?
A 78-year-old male is profoundly short of breath. He has a history of congestive heart failure. His oxygen saturation is 80% on room air. EMS calls medical control because there is disagreement about which hospital to transport. The closest, Hospital A, is five minutes away, while Hospital B has an ETA of 15 minutes. The patient is markedly confused. His wife demands he go to Hospital B, because that is where their physician is on staff, and he said he would meet them. EMS is concerned about the prolonged transport time. What should medical control do?
The patient is in respiratory distress and obviously lacks decision-making capacity. He can't refuse transport to the closest facility. Does his wife have standing to demand further transport?
Although spouses may think they are each other's legal guardian, they are not. A legal guardian is appointed by a judge when an individual is deemed incompetent. This individual can be a spouse, but marriage does not confer this authority. In this case, if the wife was the patient's legal guardian, then she might influence the decision. A power of attorney for health care is empowered to make all medical decisions for the patient when the patient cannot. That status was not present in this case. The various states have health care surrogate acts, but this emergency situation would not allow for clarification of its applicability.
The patient is in critical condition, so although EMS would like to accommodate the wife, her demand should not be honored. Essentially, one person cannot condemn another to death. The patient lacks decision-making capacity and his spouse is interfering with the ability to provide the appropriate medical care.4,5 In this situation, we must assume what a reasonable person would want in the absence of an advance directive, and treat the patient accordingly. This patient should be sent to the closest hospital.
Advance Directives: Fact or Fiction?
EMS is dispatched to a local nursing home for a patient in cardiac arrest. On arrival they find an 80-year-old male on the floor in the dining area, with CPR in progress. They take over the resuscitation and commence advanced life support. The monitor shows asystole. Moments later, a nurse runs up to the crew and states, "He is a 'do not resuscitate' (DNR)." The patient has a long list of chronic medical problems, including Alzheimer's disease, but no specific terminal illness. The documentation of the DNR is actually valid. (This does not happen frequently, as often an inappropriate surrogate has made the request or a demented patient has signed the form.) The paramedics initiate contact with medical control, with the hope of terminating the resuscitative effort. Would you comply?
Cardiopulmonary resuscitation is one of the few things we do to someone without their consent. It takes a formal advance directive to deter this medical modality. Anyone can have a DNR order at any time. These declarations are encouraged, and when not present in certain circumstances, are frowned upon by medical providers. Although not terminal, our patient had a valid DNR order in place. Medical control could easily order the paramedics to discontinue their effort.
As a volunteer firefighter, I responded to this call and took formal responsibility just as medical control was being contacted. A quick assessment of the situation revealed an interesting observation. Directly next to the patient was a feeding chair. On the tray of the chair were diced-up hot dogs. As the crew was contacting medical control, one of paramedics had initiated an attempt at intubation. I reached for a McGill forceps; the paramedic visualized a foreign body a hot dog. A quick grab with the McGill, some Ambu bag ventilations, and the patient regained a pulse and spontaneous respirations. He was discharged from the hospital three days later, perhaps minimally more confused than before his dinner four days prior.
Were we wrong to resuscitate this gentleman? True, he did have a DNR. However, his precipitating cardiac event was a foreign body that caused an airway obstruction, and was easily removed. Was the intent of the DNR, as most are, to prevent aggressive resuscitations and consequent admission to a critical care unit with tubes in every orifice? Does an acute episodic intercurrent event preclude the intent of a DNR? One can certainly question the appropriateness of the intervention and subsequent outcome of this case. However, would an apparent simple radio call to medical control truly have portrayed an environment that met the intent of the DNR?
The three cases presented in this discussion are all real. They demonstrate some of the difficult decisions that are placed on medical control for EMS. When does a patient's autonomous right trump our desire to be beneficent (that is, what we believe to be in the patient's best interest)? Who is empowered to make medical decisions for a patient incapable of such decisions? And, does a DNR always mean what we perceive it to be?
Medical control is much more than simple rote decisions; there will always be situations that challenge us to think, be creative, and improvise. Not unlike in the practice of emergency medicine, the liabilities are apparent, but the rewards greater.
The author expresses gratitude to attorneys Diane Jacoby and Jason Danielian for expertise and advice, and to Dawn McDermott for administrative support.
1. 42 U.S.C § 1983: US Code-Section 1983: Civil action for deprivation of rights.
2. Potts, et al, v. Board of County Commissioners of Leavenworth County Kansas, K.S.A 2007 Supp 75-6104.
3. Johnson v. University of Chicago Hospitals. 982 F.2d 230 (7th Circuit 1992).
4. Capron AM. Legal setting of emergency medicine. In: Iserson KV, Sanders AB, Mathieu. Ethics in Emergency Medicine, 2nd Ed, Tucson: Galen Press; 1995.
5. Collins v. Davis, 44 Misc.2d 622, 254 N.Y.S.2d 666 (N.Y. Sup. 1964).