Boundaries

     EMS Reruns is an advice column designed to address dilemmas you may have experienced in EMS that you did not know how to handle. But it offers you a luxury you don't have on scene: plenty of time to think. If you think of an example like the one that follows, send it to us. If we choose to publish your dilemma, we'll pay you $50. We don't know everything, but we do know a lot of smart people. If we need to, we'll contact just the right experts and share their advice with you. E-mail ideas to Nancy.Perry@cygnusb2b.com.

     Antoine LaMer is an 80-year-old grandfather and former member of the French Underground. You've been called to his home tonight, where he collapsed while making spaghetti for his own birthday party. According to his daughter, he had been complaining of headaches all week. He was talking to family members when his speech suddenly became unintelligible and it seemed as though he couldn't close his mouth. He appeared to be collapsing, so several family members eased him to the kitchen floor.

     You find him there, supine, with a pillow under his head. He appears to be in very good physical condition. He is awake and appears alert to his surroundings, but he cannot speak. He has a mild-intensity cough and is drooling, and you suspect the cough is related to his inability to swallow his secretions. He nods or shakes his head appropriately in response to your questions. You learn that he has an occipital headache, which he can localize with either hand. He obeys commands, and his muscle tone is about equal in four extremities. His eyes track normally, and his pupils are equal and reactive at three millimeters. He is incontinent of urine and seems very embarrassed about that. His vitals are within normal limits except for his blood pressure, which is a little high.

     Your impression is that Mr. LaMer has had a stroke. To help him manage his secretions, you position him on his left side and apply oxygen via a non-rebreather mask. You cover him and initiate transport toward your area's new regional stroke center, which is about 30 miles away, contemplating an IV en route. But before you can even get your patient in the ambulance, your medical control physician redirects you to his community hospital ED, some three miles away. That doesn't seem right, and you tell him so, but he insists.

     Q. You're pretty sure your doc is making a mistake here. You know him pretty well, and he's not your favorite physician. You're tempted to disregard his order. Should you?
     A. Definitely not. Although it probably would be ideal for every stroke patient to be seen promptly at a stroke center, your doc has accepted the responsibility to make a lot of decisions for which he has earned the necessary authority. If your system gives him that authority and you act against his directive, you're really out there on your own. Better do as he asks.

     Q. Your ambulance isn't on the road more than a minute when the physician calls you back. Apparently the patient's wife had consulted his HMO insurance carrier and the local ED prior to calling 9-1-1, and your doc has been in contact with the HMO's hospital. You're being redirected again, this time to the HMO hospital. You wouldn't take your dog there, actually, and you're pretty upset about his decision. Now what do you do?
     A. You do have a choice about your dog, but you don't have a choice about this patient. You pretty much have to take him to the HMO hospital.

     Q. What if the patient says he wants to go to the stroke center? Isn't there a way you could share your concerns with him and let him overrule everybody?
     A. Actually, there is. If the patient makes that decision without your input and indicates that he wants a destination or a treatment, he's the boss. But beware of giving medical advice to people who trust you-even if they ask for it.

     Q. Shouldn't an EMT or paramedic be a patient's advocate first? Surely they're better informed about their own EMS system than the public is.
     A. The best way to advocate for sick people is probably to go to medical school. As an EMSer, you're in a position of great trust despite a wimpy medical education. If a patient looks you in the eye and asks for your advice, there's no ignoring the situation. Here's what I would say: "Sir, (Ma'am), you should never get your medical advice from a paramedic. You should get it from your doctor. But because you asked, if you were my dad (mom), this is what I would tell you."

     As for giving unsolicited advice contrary to a physician's order or the advice of a patient's own physician, I don't think you have the horsepower to go there.

     Nor, perhaps, the right.

Thom Dick has been involved in EMS for 35 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 Magazine's editorial advisory board. Reach him at boxcar414@aol.com.