Fatal Mistakes in Prehospital Medicine

The admonition “First, do no harm,” has been a maxim of medical care since the days of Hippocrates. The phrase reminds healthcare providers to first consider the potential harm an intervention might do. In some cases, it may be preferable to do nothing rather than risk that potential harm.

With the limited tools available for the provision of BLS care, often the greatest harm is caused by not acting, but the decision-making process is far more complex for ALS providers. Not only can we act with everything in the BLS arsenal, but we have a broader array of tools, skills and knowledge to provide lifesaving care and, potentially, harm. And few tools in the prehospital care arsenal have as great a potential to cause harm as the laryngoscope, the syringe and the ink pen.

Inappropriate AMA Refusals

One may think the greatest risk of obtaining an AMA (against medical advice) refusal is to the EMS provider, but one study showed no significant difference in hospitalizations or deaths in comparing patient-initiated refusals versus provider-initiated refusals.¹ In other words, patients are just as likely to suffer adverse outcomes when we refuse to transport as they are when they refuse transport against our advice.

Refusal of care, both patient-initiated and provider-initiated, is an area fraught with legal liability for EMS providers. Inappropriate AMA refusals may result in disastrous consequences for the patient and the provider.

The first step in obtaining a legally defensible AMA refusal is determining if the patient is competent to refuse care in the first place. Traditionally, EMTs have documented the patient’s level of alertness (awake, alert and oriented to person, place, time and event) as a means to demonstrate the patient was competent to refuse care, but this practice leaves much to be desired, both ethically and legally.

A signature on a refusal form accompanied by the magic phrase “AAOx4” does precious little to shield the provider from legal liability. While it is relatively easy to justify taking a patient to the hospital, leaving them at home requires a good deal more assessment and thorough documentation. Before you obtain a patient refusal, you must first perform and document a thorough patient assessment, including the patient’s present mental capacity, of which their level of alertness is but a small part.

What most EMTs fail to realize is the shorthand “AAOx4” is a conclusion. A lawyer would phrase it as a conclusion based upon facts not in evidence, and if you don’t include those facts in your documentation, the jury doesn’t get to hear them. It is better to document the facts, and let those reading your report—including jurors—draw the obvious conclusions.

Determining present mental capacity hinges on the following elements: memory and recall, orientation, and cognitive ability. By taking five minutes to have the patient answer a few questions and perform a simple mental exercise, and documenting the patient’s answers to those questions, you can adequately demonstrate that the patient was indeed competent to refuse care—or reveal a patient at risk of further deterioration that a cursory examination of their orientation may have missed.

Memory

Ask the patient to memorize four simple words—horse, apple, car and television—and tell him he will be asked to recall those words later in the exam. Have him repeat the words aloud to you, and tell him to remember them.

Orientation

Rather than document the conclusion “AAOx4,” instead document the questions you asked, and the answers the patient provided. Leave the conclusion to the person reading your report.