When No Means Maybe

I was recently out doing one of my last field observations of spring quarter, close to graduating another group of paramedic students.

I was hoping to see this particular student run another call or two when my wish came true as the tones went off and we rolled out the door for a “man not feeling well.” I’ve been on my share of these calls and they are generally a crapshoot—could be a crisis, could be nothing of consequence, could be anything in between.

Once on scene, the student led us through the front door and found his patient looking somewhere between uncomfortable and miserable, seated in his lounger in the living room. The assessment went well, and the student quickly realized that he had a very sick patient, made more complicated by the fact that much of what was ailing the man had stacked up in the last few months.

The downhill trend had started when his wife of 53 years had unexpectedly passed away six months earlier, and the recent widower was struggling with depression. He started drinking heavily and two months later was diagnosed with diabetes. The patient had a two-year history dealing with unstable angina that had recently transitioned into right heart failure, as evidenced by the 3+ pitting edema of his ankles. Between the drinking, poor eating habits and medication non-compliance, this man was in dire straits.

The student was on his game and quickly called for CPAP. As is often the case, the patient quickly improved, which complicated matters when it came time to discuss transport. The student asked the question and in return got an immediate and resounding, "NO!" The student knew that the CPAP was not a solution, really only a Band-Aid, and tried to explain that to the patient. A simple shake of the head said that nothing had changed. At this point the patient’s son had arrived and he took his turn with his dad, and unfortunately was met with the same response. During their exchange we now found out that his wife had been transported to the same facility that we were recommending six months prior and had died due to a medical mistake. The patient had no confidence in the care facility, and felt that the same thing would happen to him.

Now the medic preceptor weighed in to see if he could turn this around and that gave me a chance to step aside with the student to talk about plan “B.” I looked at him and asked, “Do you think he needs to be transported?” “Absolutely!” came the immediate reply. I leaned over and quietly said, “Then in this case, let’s assume that 'no' really means 'maybe,' and you need to work to make this transport happen.”

We encounter these decision-making challenges all the time in EMS. In cases like this, with the immediate improvement from the CPAP, the patient is less inclined to say yes to the transport. Given what had happened to his wife, only made matters worse. Much, much worse.

What needs to happen is to quickly ascertain if the patient is truly a no, or possibly a maybe. If you determine that they are a no, there is no benefit to be gleaned from pushing the patient and turning the event into an argument, especially with a patient with a brittle heart condition. Increasing the stress for these patients increases cardiac workload, which in turn increases oxygen consumption, further destabilizing the myocardium. That’s never good and can potentially be catastrophic.

These are dangerous encounters especially with any patient having a cardiac emergency, and have to be handled with great sensitivity. It is a fine balance of trying to get the patient to think logically in a stressful setting, without adding unnecessary stress during the process.

In the end, we spent another 20 minutes on the scene, as the student got another shot at getting the patient to say yes, as did the son and the preceptor. The deciding factor was getting his two grand-daughters on the phone who pleaded for him to go to the hospital so that they could keep him around. Reluctantly, he gave us the nod. Enroute, the preceptor and the student worked diligently to calm the patient and to convince him that the care facility was a good one (which it truly is) even though they had made a fatal mistake with his wife.

In summary, it’s often easier to take a no response to transport and sign the patient AMA, though in truth, it’s not good medicine and it’s not what the patient needs. Being sensitive, but still focused and diligent with your efforts to get these patients to agree to transport so they can get the definitive care they need, can really put your people skills to the test. You just have to determine if no means no, or if no means maybe.

Until next month….

Mike Smith, BS, MICP, is director of clinical education and lead instructor for the Emergency Medical & Health Services program at Tacoma Community College in Tacoma, WA, and a member of the EMS World editorial advisory board.