`Fessing Up

   It's clear, but there's ice in the air as you open your cab door and step into the night. You've followed the telltale signs of a vehicle off the road --tire tracks, the crumpled end of a corrugated steel guardrail, and the fresh glitter of crystallized glass on the asphalt. Your flashers punctuate the darkness surrounding a vague shape 30 yards to your right and slightly downhill from you, and you soon illuminate the area to reveal a small red sedan. It's heavily damaged but resting on its wheels. There's light-colored vapor or smoke rising from what was once its hood. You can detect no odors. You update the incoming engine company, drag your stuff out of the compartments and proceed down the hill.

   There's a sole, restrained occupant seated behind the wheel, and an air bag is deployed in front of her. She's awake and whimpering, but she appears dazed and doesn't seem to hear some of your questions. The engine pulls up with its added lighting and personnel, and they soon locate a second patient. They quickly call for a chopper and designate an LZ. Your partner, Mert, checks out the other patient, a 30-year-old apneic, pulseless male with deformative cranial injuries and extruded brain matter. He's farther downhill, and it appears he was ejected and thrown clear of the vehicle as it rolled. You elect not to work him.

   There's a Level III trauma center 20 minutes up the road, and you've just decided to cancel the chopper when you hear it overhead. You relay your decision to the company officer, but you can hear the chopper landing, and soon there's a flight nurse hovering over you. You tell her you don't need a chopper, but she starts repeating your assessment nonetheless. The patient's mentation is lightening, you see no reason for a flight, and the nurse's assessment reveals nothing new. Still, she talks the patient into flying to a Level I facility about 30 miles away.

Q. This happens all the time in our area. I hate it. The chopper is based at an industrial complex adjacent to our district, and their crews consistently pressure us to let them fly patients who don't need to fly. It's like private ambulance games. It adds risk, it's an unnecessary use of resources, it's costly to patients and it's not right. What can we do?

   A. Not all chopper crews are alike. But these are medical decisions, and they should be made by the highest available medical authority. Contact your medical control for a disposition on this patient. Later, talk to the chopper crew courteously and personally.

Q. There's a recession, you know? A lot of people in our service area don't have medical insurance. I feel responsible when I know they're going to receive a $10,000-$15,000 bill for a flight they don't need. Don't patients have a right to informed consent for the cost of flying? They're sure not going to get that information from the flight crews. Considering the whole situation, shouldn't I inform them?

   A. I've had patients ask me about the cost of flying, and I think when that happens you need to give them your best understanding of the truth. I think flying is a form of therapy, no less than ground ambulance transport is, and the cost of ground transport is high enough. I think you should be honest about that as well.

Q. Agreed, but I'm not just talking about answering their questions. I'm talking about informing them. They trust us completely, and for a lot of the people in our service area, an unanticipated $12,000 bill can mean bankruptcy, disgrace and life on the street.

   A. I can't help respecting your honesty and your commitment to the public. I think you're right. When you're sure you're right about something and it's worth a gutter fight, you may end up there. But it sounds like you're also struggling with a system problem. Someone a little taller than you may need to shoulder their share of that responsibility. I think you should ask them to cowboy up and do that before you presume they won't.

   With that said, I agree with you. We all should be able to look every conscious patient in the eye, ask permission for anything we do, and explain truthfully why we think it's necessary.

   Thom Dick has been involved in EMS for 40 years, 23 of them as a full-time EMT and paramedic in San Diego County. He is the quality care coordinator for Platte Valley Ambulance Service, a community-owned, hospital-based 9-1-1 provider in Brighton, CO. Thom is also a member of EMS World Magazine's editorial advisory board. E-mail boxcar_414@yahoo.com.