Your Patient Assessment Is A Matter Of Homeland Security

The title is true. America's national security could depend on your patient assessment and transport decisions. Here's how.

A good percentage of the time- maybe 30%, but it all depends on the day or the territory you're working- we'll arrive on scene to find a patient who doesn't want to be transported, or in some cases, to even be evaluated or treated. We've all got different terms for the form or procedure for allowing a patient to decline care, but I'll use the commonly-recognizable "refusal."

Most of our patients (at least, the ones who aren't frequent flyers) hold the misconception that the decision about hospital transport is mostly up to us, the EMS providers. But unless they've passed out or are exhibiting obvious cognitive impairment (alcohol, severe mental illness, head trauma, etc) it's really up to them to make that decision. So we're left in an odd sort of limbo- a patient with a minor complaint that doesn't appear obviously life-threatening being told the decision to go to the hospital is up to them.

So our patient has all the decision-making power, but not as much of the expertise. We've got the expertise, but in the field, we may not have all the information. It makes for a gray area, especially with those patients with minor complaints. Add to that the fact that on our end of the stethoscope, we're privately weighing a couple of different factors on whether to recommend transport. These include-

1) Enlightened self-interest. We want what's best for the patient, because we'd rather not have to explain our lack of suspicion that Grandpa's indigestion would later blossom into a massive MI. This is the exception to the rule, however; the majority of these on-the-fence incidents turn out to be nothing, and we'll probably face down a baleful glare from an overworked charge nurse. But from a purely risk-management point of view, if they call, we should really haul.

2) On-scene time. If our patient gets into a lengthy discussion with a significant other, a child, a caregiver or a recently-departed relative who they're SURE they see over their shoulder, our judgment may be clouded by the fact that dispatch is going to get grumpy about how long we've been out of service. We may be pushing the patient one way or the other, even subconsciously, just to get the call resolved.

3) Personal priorities. It's a lot easier to clear a call with a refusal than it is to transport to the hospital, fill out a patient care report, wait for a bed, give report and clean up the unit before returning to service. We may be hungry. We may be exhausted. Shift change may be right around the corner. It may be hot or cold and we just want to get back somewhere comfortable. We may not admit it, but we're thinking about it.

4) Hospital status. No one wants to take a patient with a sprained ankle or chronic constipation across the county because all the local hospitals are on bypass, or to wait on a nearby ED for two hours because they haven't got any beds available for your Priority 3. Patients don't like long hospital waits either, so if we say "You'll wait a long time to be seen," we're prejudicing them against transport.

Are any of these considerations bad things? Of course not. We're humans. But it helps to take an honest look at the factors we consider in the field beyond simply patient interest.

I would propose one other factor to consider. (Hauls out his soapbox.) Good patient assessment by EMS in the field will help our healthcare system. If we as EMS providers, ALS and BLS, bust our backsides to do a comprehensive, quality assessment of our patients, and document the hell out of it too, then we'll have a lot more support in making our decisions. That charge nurse may not be quite as displeased when we arrive, and if our patient refuses care for something that ultimately requires hospitalization, we have facts to back us up.

So why does this help the healthcare system? If we cut loose a truly non-emergent patient to seek help from their primary care physician or to simple recover without hospitalization, that reduces the strain on hospital emergency department beds and keeps costs down. If we transport a patient who doesn't look THAT sick, but manages to avoid complications due to early hospital care, we alleviate the strain on the healthcare network those complications would have imposed. EDs across America are swamped with nonemergent cases. If you can responsibly steer your patient to alternative therapy, you help- in a small way- to alleviate that strain.

In short, don't just transport because it's safest for your career and risk-free for your patient. A high-quality patient assessment is the best factor in your transport decisions, and it helps keep the emergency department prepared for true emergencies, like floods, disasters and terrorist attacks. And that's a homeland security issue. So get that second set of vitals- your country is depending on you.