Minors and Refusals

[helicopper 1,050]

Another ongoing discussion on this board concerning issues about RMA's involving persons under 18 caused me to wonder about the answer to this scenario:

Your EMS agency is dispatched to a motor vehicle accident with injuries. Upon arrival (or even enroute if you prefer), you're advised by PD that there are no injuries. The caller reporting the accident was not one of the involved motorists and was just "passing by".

1. Do you still contact the occupants of the vehicles or do you go back in-service having been cancelled at scene or unfounded (no injuries)?

2. If you make contact with the occupants do you make them sign an RMA even though they are claiming no injuries and did not call for your services?

3. If one of the occupants is a minor (less than 18) what do you do about them?

I'm curious about how these situations are handled because I've seen them go a bunch of different ways - including some arguments with "patients" about refusing "treatment".

Since we're all going to be hunkered down riding out the big "sub-tropical storm" tomorrow there should be lots of time for everyone to respond...

[JetPhoto 626]

Excellent topic, My rule is that if I go to a scene and the I talk to the person they get an RMA. If I'm canceled by a competent person (someone I know that is trained) then I consider my self canceled and off I go.

How many people actually do Ram's for someone lets say driving along hit a pedestrian. Now the pedestrian get medical attention obviously but what about the occupants of the car? They are also a patient until deemed otherwise.

[helicopper 1,050]

Excellent topic, My rule is that if I go to a scene and the I talk to the person they get an RMA. If I'm canceled by a competent person (someone I know that is trained) then I consider my self canceled and off I go.

How many people actually do Ram's for someone lets say driving along hit a pedestrian. Now the pedestrian get medical attention obviously but what about the occupants of the car? They are also a patient until deemed otherwise.

If a competent person states that they are not injured - what exactly are they refusing? The evaluation and offer of assistance to the driver of a vehicle who hits a pedestrian is a good call but again, when someone states they are not injured and declines your assistance, why compel them to sign a refusal of treatment (what treatment were you offering them anyway?).

Here's a real twist now - does your agency bill people who RMA? I know someone who received a bill from an EMS agency for $50.00 for an RMA? Now that really muddies the water, doesn't it?

[Guest]

Excellent topic, My rule is that if I go to a scene and the I talk to the person they get an RMA. If I'm canceled by a competent person (someone I know that is trained) then I consider my self canceled and off I go.

How many people actually do Ram's for someone lets say driving along hit a pedestrian. Now the pedestrian get medical attention obviously but what about the occupants of the car? They are also a patient until deemed otherwise.

Yes, very interesting. If you were to follow the "everyone's a patient" mentality...we would be running MCI's all day, thereby taxing our internal resources, et.

While I bellieve the State of New York has no real set dicipline on this....I have been taught that the second you break out the BP cuff, or start assessment on a "one on one" status, the person ascends to "patient" status, and a PCR is required.

I know there are multiple ways to handle this particular senario...I would be interested to hear other points of view

stay safe.....

[firemoose827 324]

I have been a part of many discussions involving this topic and I have been a part of many ACTUALL cases in the field. To be honest, we can talk about this untill we are blue in the face, but with all the legal issues Im covering my but every time and doing what I feel to be right...for both the PT, my crew and I. These are all "What if" scenarios that I am sure everyone here on these forums encounters every day. If I am enroute to an MVA and a PD unit is on scene telling me there are no injuries, everyone refused medical aid there is two ways to handle the situation...If you trust the PD than you return to service and return to station. If something happens Im sure the PD unit has taken the information from the pt and has documented the refusal of treatment, and the dispatch center has the tapes of the ambulance being cancelled on the air.

What I would do is different than what most of you would do though...I know and trust my local village PD units, 2 of them are on volunteer fire depts and rescue squads and they actively assist my volunteer squad all the time as we are simultaneously dispatched to EMS calls in the village. They know to have us respond incident under control and check out the pt's anyway. We will go to the scene, ascertain LOC and if any injuries are present and if they are A&OX3 we have them sign off with PD witnessing. If they are underage the PD unit contacts a parent/gaurdian and receives permission to release the minor. It works out well for us, I AM NOT SAYING THIS IS HOW EVERYONE SHOULD HANDLE THE SITUATION. This is the way we do it here and we have had no problems. I always air on the side of caution and cover my but and keep my organization in mind and protect them as well. It takes two minutes to do a quick assesment and get a signature.

This is a good topic that we all should be talking about and sharing our experiences with each other on. Im interested to find out how other agencies work with their local PD and what they do in these situations. To all of you members who ARE PD, what advice do you have for us EMS? I think our EMT training should have more detailed lectures on the subject of legal issues in EMS, when I went through the initial EMT class in 1994 we received a brief lecture on the legal issues, just barely touching on each aspect and then we were on to the next lesson. Are there any instructors out there who agree? Disagree?

Stay dry in the "Hurricane" were supposed to have Sunday and stay safe. Hopefully it misses us alltogether!!

[JJB531 652]

No Injuries = No Patients = Cancelled on Scene/No Founded Patients

[Guest mediconpatrol]

I think the other part of the answer is that if PD cancels while you are enroute and there is a pediatric patient then PD is taking responsibility of patient.

I have arrived on scene to such calls. If all adults say I didn't call you then there is no patient. If juvenile is involved and parent is not present I generally try to reach them by telephone to see if they would want transport. If they say yes, I do so, If they say no I have PD witness telephone conversation and sign PCR.

[ltmdepas3280 1]

No Injuries = No Patients = Cancelled on Scene/No Founded Patients

I am the EMS director for our department (upstate) and after a lenthy conversation with the NYS Health Department and our Medical Director, the ruling they gave us was as follows.

1) If you are cancelled enroute that falls under "No Patients Found" PCR not required

2) If you are on scene and TALK to the person involved and they refuse any TREATMENT or DENY INJURIES PCR required but they do not have to sign off. It falls under no Patient found....the talking thing

3) If you are on scene and TOUCH the person (ex; take a pulse or b/p ) TREATMENT PCR REQUIRED!

Very important thing to remember when in doubt do the paperwork it could save your job!

[Guest alsfirefighter]

Good topic Chris!

"Medic 1 to 60 Control, Medic 1 will be in-service no medical needed." PCR completed documenting the same.

If they do not have a complaint and there is no obvious injuries then they do not need an RMA.

A person who is driving a car and strikes a pedestrian is not a patient.

ltmd...great post and thank you for sharing that, many providers do not know that they do not need a signed RMA.

Any call you are dispatched to or any stand-by you do, a PCR must be generated.

Jonesy you also made great points.

I do not perform my responsibilities or duties with the thought of lawsuit in the back of my mind. If you do your job in a competent, professional manner you will have no problems.

[RWC130 594]

alsfirefighter,

"Medic 1 to 60 Control, Medic 1 will be in-service no medical needed." PCR completed documenting the same.

I've NEVER heard you say that before.

I've always hear you say "In-service, call going BLS"

LOL!

[JetPhoto 626]

I look at this way an incident happens today, we will say minor MVA. you get their and the people tell you "I'm OK" you go with no patient found. Now here we are a year later, and the occupant of the car is sueing...you because they actually were injured but the ambulance just showed, spoke to us and left. Now keep in mind they say now that "They did say they were hurt but you didn't help them." Where's your proof? a small note on a blank PCR saying no patient found?

Now lets say they are suing you because you were their and didn't transport them to the hospital even though they were hurt. This time you have a PCR signed by the patient that says (well we know all the flabbier). Guess what you have something in your favor.

Just my opinion, since the state doesn't want to do anything about that "Grey" area, who is right and who is wrong?

[Guest alsfirefighter]

Now lets say they are suing you because you were their and didn't transport them to the hospital even though they were hurt. This time you have a PCR signed by the patient that says (well we know all the flabbier). Guess what you have something in your favor.

OK. Now tell me what their lawsuit is going to claim? Unless there was an obvious injury or condition which you didn't attempt to treat and the failure to either do something or the lack of doing something caused an injury or condition or caused it to make it worse they have no basis for a case. In addition RMA's are the highest percentage of litigation in EMS so regardless of whether or not they signed the RMA you could still attempt to get sued. How many people actually document an RMA the way it really should be? How many providers are at a minimum annually trained to properly document RMA's?

[ckroll 101]

Yes, very interesting. If you were to follow the "everyone's a patient" mentality...we would be running MCI's all day, thereby taxing our internal resources, et.

While I bellieve the State of New York has no real set dicipline on this....I have been taught that the second you break out the BP cuff, or start assessment on a "one on one" status, the person ascends to "patient" status, and a PCR is required.

I know there are multiple ways to handle this particular senario...I would be interested to hear other points of view

stay safe.....

If it is medical and we are responsible, then NYSDOH has it in writing. Policy statement 02-05, Pre Hospital Care Reports, page 5 lists meaning of all disposition codes.

008 No Patient Found

" If a service arrives at a scene and there is no one there with any complaint or injury, this code should be used. This would include being dispatched to a motor vehicle crash at which there are no persons who require any evaluation or care to. Document completely under comments.

005 Refused Medical Aid and Or Transport

" Any time contact is made and a person is evaluated, to include such procedures as vital signs being taken, or any treatment provided...."

Definition of patient:

1. a person who is under medical care or treatment.

2. a person or thing that undergoes some action.

3. Archaic. a sufferer or victim.

Definition of victim:

1. a person who suffers from a destructive or injurious action or agency: a victim of an automobile accident.

2. a person who is deceived or cheated, as by his or her own emotions or ignorance, by the dishonesty of others, or by some impersonal agency: a victim of misplaced confidence; the victim of a swindler; a victim of an optical illusion.

If one does not undertake action involving a person-- by providing treatment or care--, then that person is by definition not a patient. Document under comments. If it is one's intent to make a call billable, then by all means touch the individual and take vital signs, thereby making them a patient. If you do, you need to know what your agency requires and what the ramifications will be. NYSDOH is specific that pre-hospital providers explain to individuals the outcomes of their decisions. If a person asks to be "checked out" and this will result in a fee for service, then the provider needs to make that clear.

To provide care defined as "to watch over, to be responsible for" means that we as providers of care do not take advantage of others misfortune. Following an MVA, police will be dispatched, as will fire and BLS ambulance service, and a tow truck. It is commonly understood that one will not be getting billed for police activity, or fire services, or ambulance service unless it is used. Towing and ambulance transport are recognized as billable events. If one works for a paid service that intends to bill for services, then that needs to be made clear so that the individual can make an informed decision. Billing for services is fine; the process just needs to be clear. To do less falls into the second definition of victim--a person who is deceived or cheated, as by his or her own emotions or ignorance, by the dishonesty of others--. Individuals who have experienced an MVA are not supposed to be rendered victims AFTER we get there.

If the sole purpose of a PCR is to cover the assets of the pre hospital provider, then that care is directed to the provider, not the individual for whom you were called, and you should be putting your name at the top, not his. [ and perhaps getting billed]

None of which addresses the issue of minors. Ethics and common decency ought dictate that a minor be left in the care of a competent, legal adult and that a legal guardian be the primary decision maker. Back to NYSDOH, however, if the individual has no complaints or injuries and is competent, then it is not at all clear to me that a minor is a 'patient' in need of MEDICAL care.

More than one police officer or school nurse has tried to make their problem my problem by claiming there is some law that all children belong in hospitals. I cannot find it and would be forever grateful if someone out there could direct me to it. What is expected of us, as care providers, is that we make good decisions in accordance with protocols, that we keep everyone informed of our actions and the consequences of those actions and that we document what we do.

[ny10570 745]

Our paperwork in NYC doesn't really accommodate no patients found and the sheer number of PCRs generated for RMAs is a burden. Thankfully we have the beautiful new code 10-91. There was an incident (MVA, fire, stand-by, etc) but no patients. We also have good old 10-90 where EMS activation was unnecessary, misunderstanding, or just unfounded. For those wonderful calls when the patient says they didn't want an ambulance and have no complaints, but an over protective whoever called. If I had to generate paperwork on every call my all ready had to come by meal breaks would disappear.

[helicopper 1,050]

If it is medical and we are responsible, then NYSDOH has it in writing. Policy statement 02-05, Pre Hospital Care Reports, page 5 lists meaning of all disposition codes.

008 No Patient Found

" If a service arrives at a scene and there is no one there with any complaint or injury, this code should be used. This would include being dispatched to a motor vehicle crash at which there are no persons who require any evaluation or care to. Document completely under comments.

005 Refused Medical Aid and Or Transport

" Any time contact is made and a person is evaluated, to include such procedures as vital signs being taken, or any treatment provided...."

Definition of patient:

1. a person who is under medical care or treatment.

2. a person or thing that undergoes some action.

3. Archaic. a sufferer or victim.

Definition of victim:

1. a person who suffers from a destructive or injurious action or agency: a victim of an automobile accident.

2. a person who is deceived or cheated, as by his or her own emotions or ignorance, by the dishonesty of others, or by some impersonal agency: a victim of misplaced confidence; the victim of a swindler; a victim of an optical illusion.

If one does not undertake action involving a person-- by providing treatment or care--, then that person is by definition not a patient. Document under comments. If it is one's intent to make a call billable, then by all means touch the individual and take vital signs, thereby making them a patient. If you do, you need to know what your agency requires and what the ramifications will be. NYSDOH is specific that pre-hospital providers explain to individuals the outcomes of their decisions. If a person asks to be "checked out" and this will result in a fee for service, then the provider needs to make that clear.

To provide care defined as "to watch over, to be responsible for" means that we as providers of care do not take advantage of others misfortune. Following an MVA, police will be dispatched, as will fire and BLS ambulance service, and a tow truck. It is commonly understood that one will not be getting billed for police activity, or fire services, or ambulance service unless it is used. Towing and ambulance transport are recognized as billable events. If one works for a paid service that intends to bill for services, then that needs to be made clear so that the individual can make an informed decision. Billing for services is fine; the process just needs to be clear. To do less falls into the second definition of victim--a person who is deceived or cheated, as by his or her own emotions or ignorance, by the dishonesty of others--. Individuals who have experienced an MVA are not supposed to be rendered victims AFTER we get there.

If the sole purpose of a PCR is to cover the assets of the pre hospital provider, then that care is directed to the provider, not the individual for whom you were called, and you should be putting your name at the top, not his. [ and perhaps getting billed]

None of which addresses the issue of minors. Ethics and common decency ought dictate that a minor be left in the care of a competent, legal adult and that a legal guardian be the primary decision maker. Back to NYSDOH, however, if the individual has no complaints or injuries and is competent, then it is not at all clear to me that a minor is a 'patient' in need of MEDICAL care.

More than one police officer or school nurse has tried to make their problem my problem by claiming there is some law that all children belong in hospitals. I cannot find it and would be forever grateful if someone out there could direct me to it. What is expected of us, as care providers, is that we make good decisions in accordance with protocols, that we keep everyone informed of our actions and the consequences of those actions and that we document what we do.

Thanks CK! Great post - when in doubt, look for DOH policy statements.

At last, guidance that says not everyone is a patient!

Now, on the subject of minors - if the occupant of a vehicle involved in a MVA is less than 18 years old but denies any injury or complaint and isn't the party who called 911, how do you handle them? Personally, I go back to your disposition code 008 because their age is irrelevant if they're not hurt but I wonder what other people do about it.

[ckroll 101]

Thanks CK! Great post - when in doubt, look for DOH policy statements.

At last, guidance that says not everyone is a patient!

Now, on the subject of minors - if the occupant of a vehicle involved in a MVA is less than 18 years old but denies any injury or complaint and isn't the party who called 911, how do you handle them? Personally, I go back to your disposition code 008 because their age is irrelevant if they're not hurt but I wonder what other people do about it.

Excellent question. Under any circumstances a minor has to be left with a major. If a minor is capable of making an informed decision, [ I define this as any child that out weighs me, but this will not work for all medics.] then I will call a parent and have child and parent agree on a go forward strategy. If a van load of brownies has had a fender bender and one has cut her lip on her braces and the mom is comfortable with the driver continuing with the care of her child, I will document, document,document and let it go.

If a child does not know who or what a president is and is still in the age of 'magical thinking' then they cannot tell you if they are hurt, or at least cannot be expected to understand the consequences of injury. That makes them incompetent to make a decision on their own.

Armpit/facial hair is considered defining for adulthood and CPR, but I am not sure if I want to go there. If the 'little shaver' is shaving, I'd call him/her an adult irrespective of chronological age. Key is understanding the consequences of a decision. Not even all 'adults' can do that. Ask good questions, look at every patient in terms of trying to rule in transport, not ruling it out and you will seldom stray off the path.

[helicopper 1,050]

Excellent question. Under any circumstances a minor has to be left with a major. If a minor is capable of making an informed decision, [ I define this as any child that out weighs me, but this will not work for all medics.] then I will call a parent and have child and parent agree on a go forward strategy. If a van load of brownies has had a fender bender and one has cut her lip on her braces and the mom is comfortable with the driver continuing with the care of her child, I will document, document,document and let it go.

If a child does not know who or what a president is and is still in the age of 'magical thinking' then they cannot tell you if they are hurt, or at least cannot be expected to understand the consequences of injury. That makes them incompetent to make a decision on their own.

Armpit/facial hair is considered defining for adulthood and CPR, but I am not sure if I want to go there. If the 'little shaver' is shaving, I'd call him/her an adult irrespective of chronological age. Key is understanding the consequences of a decision. Not even all 'adults' can do that. Ask good questions, look at every patient in terms of trying to rule in transport, not ruling it out and you will seldom stray off the path.

The van full of Brownies or a "magical thinking" little one is a totally different ball game. My focus is the little cherubs who have gained majority (or at least captain-cy) in the eyes of DMV and the law but not yet the DOH. A 16 or 17 year old gets into an accident and is unhurt yet from some of the posts I've read on this forum, there seems to be an almost knee-jerk reaction that they must be transported. That's what got me thinking about the issue. Using the disposition code 008 for no patient seems best but I've seen crews getting 5-6 RMA's from all the participants in an MVA with no injuries.

Obviously if they have visible injuries or are in some sort of visible distress, they're a patient.

CK, you use common sense as a guide but unfortunately there is no practical testing on that skill in EMT or medic school.

[Guest paramedico987]

You must keep in mind what RMA stands for. They are REFUSING emergency medical service and transportation. They can only do that if they either obviously requre said service or requested it themselves or through a third party. Most of the time this is simple; you go to someone's house for a specific complaint.

In a case of a motor vehicle accident, for instance, you help those who obviously need it and anyone else who requests it. The only time anyone would need to REFUSE service is if they are determined to require it by YOU, THE MEDICAL AUTHORITY on the scene [i.e. you believe they should be evaluated due to significant MOI]. I REITERATE, YOU DECIDE WHO IS A PATIENT!

As for minors; if you decide that a minor is a patient and they don't want to go ONLY a legal guardian can REFUSE ON THEIR BEHALF. However, if they're not patients because they neither require nor request [a parent can request for them as well] ems intervention, they are simply bystanders.

We ALL go way over the top covering our a$$es because we're terrified of getting sued. Don't be. The only way you're gonna get in trouble is if YOU refuse to help someone or allow someone who is GRAVELY ILL OR INJURED to refuse assistance. Everybody else has had ample opportunity to get the help they need.

[firemoose827 324]

Just as an afterthought to this topic, something I thought about this weekend at work as I responded to my second MVA, I have responded to MANY MVA's where theres law enforcement or a Fire Chief on scene stating there is "no injuries" and to respond at our discretion or not at all. We responded to the scene and found at least one person with cuts and bruises, or GASHES, bleeding, shaking, and even once where the person was NOT fully alert. Now, to somewhat support what Jetphoto was saying, had we, as the EMS provider, listened to the units on scene (with very little to NO EMS experience) and simply called back in service and returned to station...what would happen to us down the road? Whos to say the person wouldnt find out later that he/she was in fact hurt and that they should have received ems attention? My simple point is, research all the facts and laws you want, the plain simple fact of the matter for ME is...Id rather argue the point of what I DID do rather than what I DIDNT do. To me, its just crazy to not take the 5 measly minutes, go say "Hello, my name is Barf, Im an EMT, are you OK?" and actually SEE for yourself the PT's Condition. That simple question alone will do most of your primary assesment for you without even touching the "PT", "Victim", "Person involved in MVA". When they answer, you see the status of their airway, breathing and if any Altered mental status exists. To me, Im already dispatched, on the scene or close to it, I just take the 5 minutes, call in service on the scene, do a quick LOC check and than have them sign anyway...Just in case...that way if they DO try and start something I take out the PCR, show my documentation, and then the SIGNATURE of the subject with PD witnessing...end of argument. This way also, looks more professional.

Im NOT trying to start anything or hurt anyones feelings here, but sharing my personal experiences. I read all of the posts with quotes from DOH and what state officials say but when you think of it, if your on the stand defending yourself, are those officials going to be there supporting us? Is the prosecuting lawyer going to just settle with the laws or are they going to look for every loophole possible? The excuse of " I needed to get back in service for the next call" will not do you any good, because the next question the lawyers ask is, "Was there a call within the next few minutes and can you show a PCR to prove it?" When Im on the stand I will have a copy of my PCR with the Pt's Signature and documentation of the fact I assesed the Pt's condition and explained the consequences of what certain injuries are capable of doing....sometimes HOURS after the fact...and the fact the Pt still refused to be treated by us. It took only 5 minutes of our time, I never layed a hand on the individuall, and I have a signature...return to station feeling better about the situation.

The topic of doing this to ensure a company can BILL for services.....?????.....In my company we cant bill unless we "Treat" the Pt. We generate a PCR for every time we are dispatched, regardless of Pt contact or not, you need a PCR for everything, even stand-bys. Asking a person how they are feeling is not treatment, getting them to sign something stating they have been told of the consequences and still refuse treatment, is not treatment. Its a step to protect yourself, your crew, and your organization from all the sue-happy individualls out there who just dont care about anyone but themselves.

Just some more thoughts to encourage further discussion. Please, no one take anything im saying personally, or as a reason to argue, because Im not arguing, just adding more fuel for thought.

Moose