RMA Strategies

[OoO 24]

I am curious to hear of other EMTs' strategies for convincing a patient who wants to RMA that they need to see a doctor.

[Guest EFFP411]

It all depends on the illness/injury, and the severity, how stubborn the patient is, etc. I have gone so far as to call family members, patients doctors, Advising them of the possibility of permanent serious injury, or illness, and/ or death. I mean, don't get me wrong, if the patient has a broken foot, i'm not going to tell them they could die from it, but if the situation is serious enough, i will the biggest pest to them for the folowing 20+ minutes. What you do have to remember is the final decision does fall in the patients hands. Even if they are having a Massive MI, if they don't want to go, you can't make them. The most you can do is make it very clear how severe the situation is, the re-precussions of their decision, then is wait for the magic internal reset button to be pushed, or wait around the corner for them realize you were right before its to late.....

ANother quick tip is if you call the hospital, and it doesn't convince them, try contacting their personal physician, it tends to have a little more effect than any random doctor.

Edited July 6, 2008 by EFFP411

[Beekman 5]

"Ummm, you're not an emergency and the Emergency Rooms are real busy right now so you will be waiting in the waiting room for quite a while". I've actually had a few patients talk themselves out of going. Sign here please. The backups in the ER are actually working for us instead of against us especially if the patient was recently at one.

[x129K 1,393]

strategies for convincing a patient who wants to RMA that they need to see a doctor.

I don't understand foreign languages....sorry.

[OoO 24]

RMA = Refuse Medical Attention

[x129K 1,393]

Sorry....it was a joke...I never was much for talking people INTO going....if they wanted to hymm and ha about it - we would get them to RMA and move onto the next call...if they really needed to go...we'd be back soon enough.

[nycemt728 49]

In most cases you can only go so far. Usually, I try to tell people that w/ things such as Fast Track etc they will go right in and if its nothing, then they will be out quickly with no real hastle to them, and if its not then they have gotten things taken care of before its gets worse/lifethreatening. As 129K said, if they're really that bad off, then we'll be back soon enough, usually w/ implied consent in effect.

[Danger 160]

Ha! Talking people in to going? Let's just say that if I have twenty minutes to argue with you over it then you can't be in that bad of shape. I'm not opposed to RMAs when appropriate which is, lets face, it a lot. 25 year old male with stomach ache, "my wife will follow us up in my car". Nope, she can drive you then. I'm an EMT-B, I don't have any wonder drugs or therapy to give you, just air and stare. When there is a stubborn patient that I'm concerned about I usually go to the husband/wife/mother etc. and appeal to them to convince them.

[WAS967 97]

Next to MVAs involving an ambulance, RMAs are the second most common reason you may find yourself jockeying the witness bench in a courtroom. Sure it's easy for you to say "sign here" but does the patient really know what it is they are signing? How many people EXPLAIN to a patient what it is they are really doing and what the possible repercussions are?

At my primary place of employment, the RMA protocol is rather extensive - so much so that it's actually EASIER to talk the patient into going to the hospital. Average RMA can take more than 20 minutes!

To those of you who are quick to say things like "we would get them to RMA and move onto the next call...if they really needed to go...we'd be back soon enough" I offer you this. Wait until a patient dies and you have to deal with the pissed off family and their lawyers. Then you might change your way of thinking. People will suit you for looking at them wrong. Cover your asses.

9 times out of 10 if you tell a patient "YOU MAY DIE IF YOU DON'T GO", they will go. For the other 10%, well, they must be suicidal, so they can't refuse anyway.

[RescueKujo 130]

Next to MVAs involving an ambulance, RMAs are the second most common reason you may find yourself jockeying the witness bench in a courtroom. Sure it's easy for you to say "sign here" but does the patient really know what it is they are signing? How many people EXPLAIN to a patient what it is they are really doing and what the possible repercussions are?

At my primary place of employment, the RMA protocol is rather extensive - so much so that it's actually EASIER to talk the patient into going to the hospital. Average RMA can take more than 20 minutes!

To those of you who are quick to say things like "we would get them to RMA and move onto the next call...if they really needed to go...we'd be back soon enough" I offer you this. Wait until a patient dies and you have to deal with the pissed off family and their lawyers. Then you might change your way of thinking. People will suit you for looking at them wrong. Cover your asses.

9 times out of 10 if you tell a patient "YOU MAY DIE IF YOU DON'T GO", they will go. For the other 10%, well, they must be suicidal, so they can't refuse anyway.

This post is right on. I have been on the witness stand with my name being numero uno on the lawsuit. No fault of mine, the patient lied to her mother about what I said/did right after I left the scene and she died the next day.

What saved my bacon?? Documentation. I documented in at least 4 locations on my paperwork the patient's refusal and what I did in my attempt to get her to reconsider. As a matter of fact, 10 years after the fact I'm sitting in a class regarding legal issues and the lawyer (who represented me and the company at the time) starts talking about how documentation saved this EMTs butt a few years ago.

So as I used to say to the new hires that were on my unit when I was in the field, it is much easier in the long run to take a patient to the hospital. Document all refusals well, do a thorough assessment and pray nothing happens to that patient. While it is their decision, if something happens to that patient your company and you just got a big target painted on your back. And if you don't follow policy, your company will leave you swinging in the breeze by yourself....

[Guest alsfirefighter]

If there is a reason that they should truly go....then whatever it takes. This is where your experience as a provider can really shine as you learn to read people over time and really listen to the reasons as to why they don't want to go. The majority of the time I find its the elderly who tend not to want to hear something bad or use the I don't want to bother anyone phrases. Once I figure out the reasons I counteract it and then use the correct tone of voice and attitude to steer them whether its super nice or stern to verbal judo.

WAS hits the nail on the head with RMA's. Which for some reasons end up also being the worst PCR's when it comes to documentation but should be the strongest. #1 litigation against EMS is RMA's. Doesn't mean you have to beat people over the head for all you CYA...the sky is falling with lawsuit types...just means do your job and document. If they are really sick and you believe they should go explain all the risks, ask several times if they want to go, get vitals (2 sets if they may have a serious condition). This isn't always a rush job...one call at a time.

[Guest Yankee medic]

The best motto I use is, "you call we haul". If pt. needs to go then take them as someone else stated if 25 y/o male with belly ache and wife will follow find another cab that is cheaper. Most times it is easier to take them than to talk them out of it.

Funny story: Easter sunday of this yr. had 30ish y/o female call for pain. Got upstairs and she put a .15$ Lee press on nail on with super glue and decided to remove it and it hurt. Mind you the hospital she wanted to go to was around the corner from her home. My partner told her to go to corner store get acetone for a dollar soak finger pull said nail off. She still wanted to go and told her I refuse to take her because the ride around the corner will be $500.00, walk into er $500.00 plus milage for the Dr. to tell her the same thing we told. She rma ed. And called 1hr later for the same thing and my county entertained this bs. But then again she didn't pay for any of the ride.

[FFD941 20]

I mean, don't get me wrong, if the patient has a broken foot, i'm not going to tell them they could die from it,

All pt's get the same speech from me..."I am offering you treatment and transport to the hospital and by signing here you are refusing my treatment. I am not a doctor nor am I an x-ray machine and you could have underlying injuries which I cannot see that could cause serious injury and/or death. If you have any further symptoms contact an emergency facility immediately."

By saying the same thing every time to every pt you eliminate that risk of not saying the "right" thing to that one pt that brings you to court.

[Guest alsfirefighter]

Clearly explaining the risks of whatever is going on in addition to reading the refusal paragraph on the back of the PCR and documenting such is what can reduce liability. Not making up your own speech.

Also in some cases as far as its easier to take them depends on your system. I do not do the you call we haul mentality. If you need medical treatment/care I will give it to you. If its something that is as minor a bit of conversation goes a long way. I spend the time on the patients I need to spend time on getting them to go and the time to get them in the bus and on the way as quickly as possible for the ones that don't.

[ny10570 745]

I never understood all the stress surrounding RMA's. If they need to go, find a way to convince them. If they still won't, let that become the doc's problem and call medical control. If they don't need to go, still do your assessment, document accordingly and get a signature. Its easy to get dragged into court, all they need is your name and address. For any legal action to stick you have to drop the ball. So long as you do your job right there will be no problems and that starts with documentation. It doesn't matter what you say to them, what they say to you, or what really happened during that call. All they care about is what you wrote on your pcr.

Edited July 8, 2008 by ny10570

[Guest alsfirefighter]

Thanks for the back up NY. Documentation is the savior in RMA's!

[Beekman 5]

If we adopted the "you call, we haul" motto, the public assist calls would come to a screeching halt. " I just needed help getting into my wheelchair and they took me to the hospital!"

As for the Fast track and no waits in the ER, that must be in the same Fantasyland where ambulances are plentiful which would not be Dutchess County or near where Mac works.

I know a lot of people blame Rescue 911 for the explosion of 911 calls, but I've seen a huge increase in RMAs, not related to MVAs, in the past few years. It just seems like there is a lot more abuse of the system with people expecting a medic or EMT to diagnose and fix their issue instead of seeing their doctor.

[Guest paramedico987]

I've got tp go with WAS here...

If I'm called for you, regardless of what the problem is or was percieved to be, I enthusiastically and unequivocally reccomend that you go to the hospital with me.

Studies have shown that we [amalance drivers of all rank and file] make very poor decisions regarding weather someone needs us and/or further medical attention. Even though you think you're darn shure that there couldn't possibly be something wrong you are required, as an advocate for your patient, to do everything in your power to make sure they get appropriate medical attention, because the consequences of you being wrong are unacceptable.

If you want to refuse medical attention from me I'm going to first tell you the same thing I tell everybody else, "IF YOU DON'T COME TO THE HOSPITAL WITH ME YOU'RE GOING TO DIE." I'm not lying, you really will die SOMEDAY.

If you're cavalier about having people refuse medical attention, and especially if you try to convince someone to refuse care, you need to reevaluate what it is that you're trying to accomplish when providing EMS and why you're doing it. If you don't want to take people to the hospital then stop doing EMS runs. Cuz, tricking someone into thinking that they don't need your help so that you can get back to your slice of pizza a bit sooner is morally reprehensible and WILL someday come back to bite you in the @$$ in the courtroom.

EMBRACE THE BS CALLS... YOU DON'T HAVE TO LIFT, YOU DON'T HAVE TO CLEAN BLOOD AND PUKE OFF OF ANYTHING AND AS FOR PEOPLE SCREWING THE SYSTEM, THE STREET IS NOT THE PLACE FOR REFORM OF THE WELLFARE STATE.

[WAS967 97]

So for those of you interested, I'll try to spew forth some Verbal Judo (<3 ALS for my favorite new term) and try to remember all of the RMA items we have to have documented at my primary employment. Phelps has a nicely made RMA card that is based off this protocol and can be obtained by visited the Hoch Center during normal business hours and subject to us actually having some in stock.

-Patient must be asked multiple times if they would like to go.

-Patient must be aware of the risks and consequences of the RMA, up to and including possible death.

-Patient must not appear impaired by foreign substances (alcohol, drugs, medications, etc).

-Patient must be considered competent to the best of your abilities, including ruling out psychiatric issues. (OMIJA)

-Patient must be informed of "follow ups" (call doctor, call 911 again if needed, go to emergency room if needed, etc)

-Must have patient signature.

-Must have witness signature.

-Must have witnesses name legible (print below is signature is not).

-Document involvement of third parties (police, family, medical control, etc).

-Document call type as recieved, and chief complaint.

-Document 2 FULL sets of vital signs.

-Document appropriate medical examination.

I'm sure I'm forgetting something off the top of my head, but if anyone has questions ("WTF is OMIJA?") please feel free to ask.

[bil14ga 1]

All pt's get the same speech from me..."I am offering you treatment and transport to the hospital and by signing here you are refusing my treatment. I am not a doctor nor am I an x-ray machine and you could have underlying injuries which I cannot see that could cause serious injury and/or death. If you have any further symptoms contact an emergency facility immediately."

By saying the same thing every time to every pt you eliminate that risk of not saying the "right" thing to that one pt that brings you to court.

Justin,

I believe that I have heard that speech before. Just remember that just saying it is not enough... You must document that you said it on the PCR. Without the proper documentation, it never happened!!! And before you ask... no you can not have any CME's for this!!!! See you in a couple of days!!!!

Chris