Not Taking "no" for an Answer...

"I don't want to go to the hospital."

It's a phrase EMTs and medics hear frequently.  To some, it is the cue to hold the clipboard in front of the patient, pointing to the signature line for refusing service, regardless of the patient's physical condition.  "I can't kidnap them," this breed of EMT will tell you, "they were alert and oriented."

Alert and oriented or not, we're medical professionals.  If someone is sick, it's our responsibility to urge them to seek treatment.  I'm not saying that everyone we see is having an emergency, or that every patient we meet is even sick, but when they are, making the case for being transported to the hospital is as much a part of our job as bandaging a wound or splinting a fracture.  Often, in an attempt to be stoic, patients will initially refuse treatment or transport, despite being in genuine discomfort.  In these cases, merely giving them an opportunity to change their mind may be enough.  Some patients require a little more persuasion.  Learning how to talk to people has been a huge part of my development as an EMT and a person.  Recently, my friend and I joked that we could convince a 23-year old triathlete in perfect shape that he needed to go to the hospital. (Of course we wouldn't... we'd probably want to get back to whatever meal, movie, or nap the call had just interrupted)

I had stopped by rescue headquarters to pick up a DVD that I needed to return one day when rescue was dispatched for a person fallen who couldn't get up.  The first-due rescue, which is typically staffed 24/7, was still at the hospital, so two EMT-Bs and I hopped into my car and drove to pick up one of the standby ambulances, calling dispatch to let them know we were responding along the way.

We arrive to find that the person who had fallen and was unable to get up had indeed gotten up, and was sitting in a chair.  This call has refusal written all over it.  The female patient, in her 70s, had tripped and fallen.  She says she is fine, just banged her knee a little.  I ask if she wants to go to the hospital.  "No way," she tells me.  I put an ice pack on her knee and explain that we're going to check her vital signs–just our standard procedure.  I clip the pulse ox probe, a device that measures the percentage of oxygen-carrying molecules that are actually carrying oxygen, to her finger.

It reads 85%, and holds steady.

The low reading makes me take a step back.  Look at the big picture, I tell myself.  The woman sits in the chair, but leans on one arm on the table.  Tripod position.  She is pale.  Most importantly, her chest heaves significantly with each breath.  

"Are you having trouble breathing?" I ask her.

"No," she replies, "I'm fine."

I take my stethoscope out and press it against her back in the upper fields.  Nothing.  I slide it low, over the bases of the right and left lungs, and hear rales, the sound of fluid in the lungs.  COPDers may have wheezes at their baseline, but nobody should have fluid in their lungs as a matter of business as usual.  We take a blood pressure, which has a systolic in the 190s.

"I can tell that you're working a little bit extra to breath," I tell her.  "Why don't we take you to the hospital so that the doctor can look you over and make sure it's nothing serious?"

"No, no... I'm fine, I just got worked up because of the fall... I just need to catch my breath," she insists.

"Well, what if we put you on our heart monitor just to be sure, and in the mean time we can give you some oxygen; it might help you catch your breath."  She nods her consent, and I put her on a nasal cannula.  Her SPO2 climbs to 90%, but she is still working hard to pull in each breath.  My partner gets back with the monitor, which I attach to her limbs.  She is in sinus tach at a rate of about 110.  

Rescue 2 calls back in town–the town is covered, so I am in no rush.  I continue to urge her to go to the hospital.  She continues to resist.  As the female EMT with me attaches EKG electrodes across the patient's chest to perform a 12-lead, I call dispatch, letting them know we'll be on scene a little while longer.  Because the patient is using the muscles that weave through the rib cage to breathe, the EKG is all but unreadable, but it may have bought me necessary time– the extra three minutes where the patient may realize they're feeling pretty lousy.  Sure enough, a few seconds after looking at the EKG, I tell the patient she should really get checked out.  I tell her I hear fluid in her lungs.  I tell her I don't want her to wake up at night feeling worse when we might be able to get it taken care of right now.  "I don't think this problem will get any better unless you get treated," I tell her.  And then I catch it.  A sideways, concerned glance.  The rook has knocked over the pawn that was blocking checkmate.  "If I went with you, what hospital would I go to?"  She asks.

"What hospital would you like to go to?"

"Well, I don't know... Could I just go to Miriam, and they would see me?"  I call dispatch to make sure Miriam is open and accepting.  They are.  "Well, I guess I'll just go," she consents.  We take her out on the stair chair, gently.  I don't want to have convinced her that going to the hospital was what she needed only to have her remember a frightful, terrible experience.  

In the ambulance, I switch her to a nonrebreather to see if the extra oxygen will alleviate her shortness of breath.  Her oxygen saturation climbs to 98%, but I can still see her using accessory muscles to breathe.  We give her nitroglycerine to create extra space in the blood vessels for the fluid that has been pushed into the lungs to return to the arteries and veins it came from, but I hold off on Lasix.  She's stable.

We arrive at the ED, and wheel the patient into a room.  We transfer her to the hospital stretcher.  The nurse accepting the report wants to establish the woman's baseline without oxygen therapy, so she removes the oxygen mask.

The pulse ox readout plummets. 

95%

85%

80%

75%

The woman gasps for each breath.  She grips the side rails of the hospital bed forcefully, a frightened look in her eyes.  The nurse has seen enough and puts the non-rebreather back on, but the woman's saturation holds below 80%.  She continues to struggle to breath.  The attending is called over.  Respiratory therapy is STAT paged to the room.  The doctor orders lasix, a foley catheter, a chest x-ray, labs, and CPAP.  "Draw up sux and etomidate for intubation, but we'll see how CPAP does first," he says to a nurse.  One minute after her oxygen therapy was cut off, our patient was in a downward spiral.  "She probably flashed," a nurse I'm friendly with tells me.  

I spent nearly 45 minutes on scene, but each of those 45 minutes counted towards making sure the patient was in the hospital, and not at home, at least 25 minutes from definitive care, when her health worsened.  I'm sorry the patient got sicker, but I can't help but feel like I did my job.  The call feels good for the three of us.