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Understanding Refusals

   The dirty blue Saturn is headed east on Highway 9. Well, mostly east. There appears to be something wrong with the driver, because the little car has been weaving erratically for the full 13 miles between a big interstate and the next town. At least once its right-side wheels left the roadbed altogether, then wandered back to the traveled portion of the undivided road's eastbound lane. Two motorists have called 9-1-1, but where the calls originate there is a jurisdictional gap in police coverage, and there are no cruisers close enough to investigate.

   Once in town, the driver manages to negotiate another three miles of surface streets, stops at a Dairy Queen for a banana split, and spills the thing while continuing to drive. That distracts him, he later tells police, and eventually causes him to collide with a parked car a block from his home.

   An ALS transport crew arrives on scene, where the driver denies any complaint. The crew gives him a quick once-over. They note that he appears drowsy and ataxic, but they don't record his vitals. He says he's a former police officer. He sustained a back injury on the job five years ago and takes oxycodone, OxyContin (they're the same), Percocet (oxycodone with acetaminophen), Soma (a muscle relaxant) and Xanax (a benzo) for pain. He says the drugs make it impossible for him to work, and openly admits to having taken all of them within the past two hours. He says he has "developed a tolerance to them" so they don't impair his ability to drive, and denies being under the influence of any substance. He declines treatment or transport.

   The crew follows their protocol and contacts a physician, who OKs the refusal (because the patient is oriented x4). But for some reason, the crew doesn't bother to have the man sign a release. They also omit a lot of information on the chart, including his identification, location and time. The state revokes the man's license for six months.

   Now he's gathering documentation in an effort to get it back. In his defense, he says the crew's documentation is "full of holes."

Q. What do we do with calls like these that are real grey areas for us? There was nothing physically wrong with this guy, except for his ataxia, and you can't just drag every fender-bender offender off to the hospital.

   A. You're right about dragging people anywhere. But attorneys have been arguing about these calls since the inception of paramedic systems. They don't have to be grey if your medical director and your agency's attorney have spelled out a few simple protocols for you. There are clear differences between a non-patient, a refusal and an AMA.

Q. What do you mean, they don't have to be grey? If lawyers have been arguing about them all this time, they're absolutely grey. We don't have x-ray vision.

   A. It's true nobody can anticipate every situation you'll ever encounter. But when you have one that's clearly covered by a protocol in black and white, and you deviate from the protocol, I think you're asking for trouble. Especially when you omit documentation.

Q. I feel bad for this guy. He was a cop who got hurt on the job. We're supposed to be helping him out, fergoshsakes.

   A. Really? That's what he said he was, and that's what he said happened. But was he? Did it? He laid some serious denial on you. He admitted taking four controlled substances two hours before that parked car jumped right out in front of him. Let's face it, he's not in a strong position to argue pharmacology with anybody.

   Don't forget, one of the ways people handle their stress (and addicts support their addictions) is by lying. This guy's a liar. He's also unemployed, so he's got nothing to do all day but work the system while you're busy earning a living. He was also drowsy and ataxic following the collision. Did you help him by overlooking the dozens of possible reasons for that, other than chemicals?

   It's OK to be wrong. But it's not OK to be fooled.

Q. Well, I have to say we run so many calls like this one, I think sometimes we just have to have the freedom to exercise our own discretion, even if there is a written protocol. Aren't there times when you just have to ignore protocols?

   A. If you do, let us know how that works out for you, OK?

   Thom Dick has been involved in EMS for 40 years, 23 of them as a full-time EMT and paramedic in San Diego County. He is the quality care coordinator for Platte Valley Ambulance Service, a community-owned, hospital-based 9-1-1 provider in Brighton, CO. Thom is also a member of EMS World Magazine's editorial advisory board. E-mail

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