Itty Bitty Boxes

   Recently, I was asked to participate in a mock trial as part of a medico-legal workshop. I was serving as an expert witness for the defense in a scenario that is arguably one of the most common and most risky in day-to-day EMS: a patient refusal.

   The case was based on an actual lawsuit. While there were a couple of minor tweaks to details, the case was presented pretty much true to form. In a nutshell, a 52-year-old male, who is a distance runner and biker, comes home after a workout and has a first-time seizure. His fiancé calls 9-1-1, and a split team of a paramedic and an EMT-B respond. The medic works the patient up and recommends transport to the hospital. The patient, who is postical, becomes increasingly alert and oriented, says he is fine now and doesn't want to go to the hospital. The fiancé weighs in and insists that he go. The medic on scene makes three or four focused attempts to get the patient to go, but in the end, it is all for naught: The patient is not budging on his decision not to be transported. The medic reads the patient the AMA refusal form and contacts a base station physician per local protocol, who signs off on the AMA decision. The patient signs the form, his fiancé signs as a witness, and the medic tells the fiancé that should there be another seizure, or if he develops any new signs or symptoms, she could call 9-1-1 again.

   The EMS team departs, and the patient says he is exhausted and wants to go to bed. Later that evening, the patient awakes with a pounding headache, takes some aspirin and goes back to bed. Shortly thereafter, he awakes again, this time from nausea, and has a vomiting episode. The next day, EMS is summoned again, this time to a patient with marked facial droop and other signs of a stroke. He is transported this time, and a CVA is diagnosed. Over the next few weeks, he has several more cerebral events, leaving him totally dependent on others for his care.

   One of the biggest elements of this case involved three or four unchecked boxes on the patient care report (PCR). While I offered up a number of logical and plausible explanations, the plaintiff's attorney wasn't bending. Shouldn't the PCR be completely and accurately filled out? Yes, of course it should. Because of these unchecked boxes, the plaintiff tried to paint a picture of an uncaring medic who was inattentive to good documentation practices and just went through the motions of patient assessment before leaving the patient and going back to quarters. That could not have been further from the truth.

   In reality, the medic performed up to his standard of care and tried multiple times to get the patient to go to the hospital. When unsuccessful, he followed the AMA refusal form to a T, gave the fiancé some directions, since she was going to remain with the patient, and departed the scene. While the outcome of this case was clearly tragic, in the end, it was the decision of a conscious, alert, informed patient not to go to the hospital that truly sealed his fate. Yet, from a legal standpoint, the unchecked boxes were a huge stumbling block. Did this represent the work of an uncaring, incompetent paramedic? While I don't believe it did, my opinion doesn't really matter. It is what the jury believes that matters.

   A complete, accurate PCR is an integral part of any prehospital care encounter, in no small part because it has three purposes. First and foremost, the PCR serves to document the assessment and care provided in the field setting. Second, the information on the PCR is also used for billing and reimbursement purposes. Last, should litigation occur, as it did in this case, your PCR is your best source of legal protection, provided it is accurately and completely filled out.

   Attention to detail is a huge part of what makes a quality prehospital provider. Sure, you may be tired from running three calls after midnight, or maybe you are on the tail end of a 48-hour shift. In fact, you may offer up a number of reasons for why you submitted an incomplete or inaccurate PCR, but, in the end, none of those reasons will fly. Part of the job expectation is to submit an accurate, complete PCR.

   As we debriefed after the mock trial, one of the attendees asked the plaintiff's attorney if he would have taken the case if the PCR had been completely and accurately filled out. He said probably not. In this case, a poor patient choice resulted in a tragic outcome, leaving his now-wife saddled with a lifetime of medical bills. However, if the plaintiff's attorney could successfully paint a picture of an uncaring medic who is willing to submit incomplete paperwork, he might well be able to win the case. As the attorney laid it out, the incomplete paperwork represented cracks in the rock that he and his team could exploit. By continuously spreading the crack, they could increase the likelihood that their litigation efforts would be successful. A complete and accurate PCR would have left them with nothing to work with, and the entire legal process would have been avoided.

   On the other hand, the more of those itty bitty boxes that you leave blank, the more likely you will find yourself roped into a lawsuit. Unlike this mock case, where no one actually wins or loses, the reality of a real lawsuit is far, far different.

    Until next month...

   Mike Smith, BS, MICP, is program chair for the Emergency Medical Services program at Tacoma Community College in Tacoma, WA, and a member of EMS Magazine's editorial advisory board.