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Final Decision


EMS Reruns addresses dilemmas in EMS. If you think of an example like the one that follows, send it to us. If we choose to publish your dilemma, we'll pay you $50. E-mail ideas to

     You're a paramedic in a busy little system, and you've arrived at the upstairs apartment of an elderly woman who wants nothing to do with you. Her daughter called 9-1-1 because her mom has been complaining of chest pain.

     Their home has the feel of a church. There are pictures and statues of Jesus and the apostles in varying sizes, watching you from every direction. They all look mighty serious, too. Some of them are lit with candles, and there's a strong odor of incense. The older woman, fingering her rosary beads, appears to be in her 80s or better. She's anxious, and you can't tell if that's a medical finding or if she's just upset because her daughter called 9-1-1. You're leaning toward the former possibility, because her color is a little pasty and she flinches when you move to touch the back of her hand. Sure enough, she's cool and a little diaphoretic. She is silent about chest pain, no matter how you ask.

     The old woman permits you to assess her, but makes it plain she won't go to the hospital. She's nauseous. Her pulse is 40, her BP is 110/90, her neck veins are distended in all phases of respiration, her lung sounds reveal diffuse rhonchi that persist after coughing, and the 12-lead suggests an inferior-wall MI. There is no spontaneous speech. She avoids your gaze and answers questions in single syllables, but you get the impression she could do a little better. You try to sweet-talk her into a trip to a cath lab. Nope, she ain't having it.

     Q. This happens all the time. Why don't people make up their minds before they call us?
     A. I feel your pain. But in this case, there were two patients. One was the daughter, who actually placed the call. That wasn't such a bad move on her part, calling in the cavalry when mom wouldn't go to the hospital. It seems clear the daughter's medical perception of the situation was about right, and she needed some support.

     Q. This old woman was really stubborn. We tried begging her, threatening her with her own death, and even taking her against her will. When we tried that last strategy, she got testy. We eventually backed off, but what were we supposed to do? We really needed to get her to a hospital.
     A. Begging was a good strategy, especially for stubborn people. But this lady was surrounded by saints. She was probably not afraid to die, and she was probably not going to let anybody separate her from her statues. Even begging was a long shot, since the daughter would have had more leverage than you in that regard. It might have been a good idea to put this lady on the phone with a physician, mortal or not.

     Q. We tried that, too. It only seemed to make her crankier. The doc told us to have her sign out AMA, like it was no big deal. That was so frustrating. We could see she was having the big one, right there in front of us.
     A. Plenty of people survive MIs. Remember, folks have been living and dying without paramedics—and their treatment protocols—for years. But choosing one's own death wouldn't be such a bad thing. Given the choice, some people would much rather die in their own home, surrounded by loved ones, than in a hospital, where at the moment of death family members are excluded by the protocols of busy strangers. This woman didn't get to be old because she was stupid, and her decision not to go to a hospital wasn't necessarily a bad one.

     Q. It just seems so exasperating, responding to people's homes with the best possible care, only to discover they don't want it after all.
     A. Makes you wish they'd read your protocols, eh? They won't, though; this really isn't about us. Medicine is something we offer people, not inflict on them. They'll always define their own emergencies in their own terms, and they'll always decide what help they want (and when). About the best you can do in a situation like this is to inform folks to the best of your ability, respect their decisions, and sincerely invite them to call you back if they change their minds.

     Not just anybody can do that. You're special if you can.

Thom Dick has been involved in EMS for 38 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 Magazine's editorial advisory board. Reach him at

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