Shortness of Patience: Does Serving Always Mean Transporting?

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. Send ideas c/o emseditor@aol.com.

Thanks to paramedic John Halbrook, NREMT-P, for his submission of the following scenario. It’s one of the best we have seen so far.

It’s 3 a.m., and the overhead alerts your medic unit to respond for respiratory distress: “Elderly female, conscious and breathing.”

Upon arrival, you and your partner walk through the door of a tired old mobile home to find a 40-year-old woman sitting on the couch, smoking a cigarette. Not sure if this is your patient, you greet her and ask what the problem is. The woman seems especially angry as she gestures toward the back bedroom. She pretty much spits her response at you: “My mother needs to go to the hospital.”

You follow her down the narrow hallway, and suddenly a much older woman begins screaming at her. The mom obviously does not want to go anywhere. Looking around the room, you notice a CPAP ventilator in the corner. You also discover a bill from a medical supply dealer. It’s stamped PAST DUE in big, bold letters.

Your interview reveals that the patient has a history of sleep apnea and that her “oxygen machine” does not work. The daughter says her mother can’t breathe and needs to go to an emergency room that’s definitely not the closest one. Mom says the mask on the CPAP machine suffocates her, so she can’t use it.

The patient’s vital signs are all within normal limits, including a pulse ox of 98% on room air. Her breath sounds are clear in all segments, and equal bilaterally. She is answering all questions appropriately (when she’s not arguing with her daughter), and she appears to be mentating well. She also relates that she missed an appointment with her doctor during the past week because her daughter was unable to take her.

The daughter insists that her mother be “cared for,” and for a moment you experience second thoughts about the younger woman’s high degree of anxiety. The daughter says that Medicaid covers all her mom’s medical expenses.

Q. Does this person need an ambulance?

A. It doesn’t seem that way, does it? But this family’s inability to operate the ventilator has produced a multiple-casualty incident that clearly needs to be resolved before the older woman dies in her sleep or her daughter blows a gasket—or they end up strangling each other. Although the older woman has the right to ambulance transport if she wants it, an ambulance isn’t necessarily the best solution—or the only one.

Q. What are the patient’s healthcare needs?

A. Whatever we do, this call warrants a consultation with your medical director, or at least an ED physician. The quickest fix would be a prompt visit from the medical equipment vendor, who needs to explain to the family how to operate their ventilator. (That’s part of their job.) Many of those companies have an on-call driver available 24/7. But it would be a grave mistake to simply leave the scene, in case that service isn’t available.

One important point about Medicaid is that they simply ignore a lot of medical expenses. As a result, many vendors do not honor Medicaid. That may be part of the problem here, although the combination of Medicare and Medicaid is a skosh better. (Is the patient older than 65? If so, she’s probably on Medicare as well.)

Q. Does getting a refusal signed help this patient?

A. It would get us back to bed. But even if she would sign one, that would be abandonment on our part. The equipment vendor has already failed this woman; we shouldn’t worsen her situation by doing the same thing. Remember, part of our job is to be there for the public when they have no one else to call.

Q. Does transporting this patient to an ED address her long-term care needs?

A. Maybe, if we can’t get any immediate support from the equipment vendor. One of the ED’s roles is to facilitate the public’s access to specialized resources from social services, insurers and law enforcement. If nothing else works, we might consider transporting her and her ventilator to the ED and having a respiratory therapist show us and her how the thing works. (An ED physician might be able to exert some clout with the equipment vendor, too.)

Q. What EMS educational opportunities present themselves in the course of this call?

A. There are several. That we’re not just here, for instance, to take people to hospitals. That our job is to serve people, in their own time and on their own terms. And that when folks call us in the middle of the night because they have no one else to turn to, that’s not a nuisance or an abuse of the EMS system. It’s what we’re here for.