A Tale of Two Doctors

Let me tell you about two phone interactions that I recently had with physicians.

The first came when I was working a shift at the airport.  In my EMS system, several paramedics posted throughout the property staff the airport.  They generally cover calls for service alone, either on crew response vehicles (fancy golf carts) for indoor calls or Suburbans for outdoor responses.  There is also an ambulance posted on the airport property for any transports, but city resources rotate through that airport post.  Anyway, I was working on one of the concourses and saw a gentleman that was flying from the east coast to the west coast, with a connection in Denver.  On the first leg of his trip he had a medical problem, so the airline requested that I meet the aircraft when it arrived to check him out.

The specifics aren’t important – suffice it to say that he had vague complaints that meant it would have been the smartest move for him to go to the hospital.  But the man had decision-making capacity and chose not to go to the hospital, even after I explained that his complaints were concerning and leaving the ground again increased the danger to him (you’re not especially close to convenient medical care while in flight, after all).  I contacted my base physician to document the against-medical-advice refusal.

When that was all done, the airline representative told me that she was going to call her physician consult service.  There are two or three companies that airlines can use for medical advice.  If there is a medical emergency in flight, the crew can call these services and get advice as to diverting the flight to the closest airport or to continue to their planned destination.  On the ground, airlines can get advice as to whether it is advisable to let the patient continue to fly.  An unscheduled diversion of a flight costs the airline a boatload of money to make up missed connections, fuel and landing fees, and stuff like that, so if you’re sick the airline doesn’t like to let you fly.  It is called boarding refusal – the airline refuses to let the person board.

In any case, I don’t care who the airline calls.  But to be nice, I said that I would hang out in case they decided to refuse him boarding.  If you get refused, the only way to get on a flight is to get a doctor to sign off on you being okay to fly.  So if the patient was refused boarding, I would use the ambulance to get him to the hospital, get him checked out, and then he could continue his travels.  But I told the airline representative that I couldn’t talk to the medical consultation service.  Of course, it wasn’t 20 seconds before she pressed the phone into my hand and I was talking to a doctor that I didn’t know.

Long story short again, our interaction was not pleasant.  The physician wanted my full verbal report, which is a violation of the patient’s privacy.  We went round and round about whether the patient could give his permission for me to give a report.  I feel like it doesn’t matter if the patient gives permission – the doctor I was talking to isn’t involved in the patient’s care.  He is the airline’s doctor, not the patient’s caregiver.  In addition, the patient isn’t making an informed decision to consent to this privacy violation – it can’t be informed without the patient being told that the likely result is that he won’t be allowed to continue on his journey.  I tried to explain all of that clearly, but the conversation got pretty heated.  The consult doctor would not try to talk to the patient directly.  I got the impression that the phone physician wasn’t hearing my point of view.  He was pretty frustrated with me and ordered me, as a paramedic, to do what he, a physician, was telling me to do.  I declined to cooperate with the phone consult, the patient was refused boarding by the airline, and the ambulance took him to the hospital to make sure it was safe for him to fly.  They actually told the patient that it was my fault and my lack of professional cooperation was causing the refusal to board. 

Contrast that story with a call I ran the very next day.  I was working a street ambulance and responded to an elderly man who definitely needed to go to the hospital.  But the patient did not want help, did not want to see me, and was angry that I was even at his house.  It took me five minutes to even talk my way in.  This call worked out that the patient was pretty sick, with sats in the 80s, tachycardia, a bunch of supraventricular ectopy, and respiratory distress.  He needed an emergency department, probably getting admitted for a hospital stay as well.  He did not want to go, however, and had no qualms about profanely and loudly letting everyone know that.  But once I could get him calmed down, I realized that he wasn’t altered or demented – he was just an angry old man.  He was funny and I liked him – I hope to be an angry old man one day.  Picture Archie Bunker, but louder and angrier.  “I’m not going to any goddam hospital, dammit! And you can’t make me!”  I explained respiratory failure, sudden death, and my other concerns for his condition and he repeated them back to me in his own words.  He understood the dangers and his decision.  He was making the wrong choice, in my opinion, but he is allowed to if he has decision-making capacity.

So I contacted my base hospital to document the against-medical-advice refusal.  In my system, we make base contact to one hospital only.  Only physicians that I take orders from are at the other end of that phone number, called the biophone, no matter where I am transporting to.  Nurses don’t answer the biophone.  This allows the attendings and senior resident physicians to get to know the paramedics.  It is a big responsibility – if I describe an incoming patient to them and arrive with a patient that looks completely different, they will remember that Bill doesn't give accurate verbal reports.  That reputation will follow me.  But if I am known for accurate reports and good decision making skills, that reputation will follow me too.  There is certainly a double-edged sword, but it works to the benefit of good paramedics.

Anyway, I explained the situation to the attending physician – that I had an elderly male who needed the hospital, but he had decision-making capacity, and that he didn’t want to go even after understanding the consequences of that decision.  The doctor asked to speak to the patient on the phone.  Some situations call for this, in that the biophone is a recorded line.  I think he wanted to confirm that the patient was competent to make that decision and save the interaction proving it on tape.  But it did not go well.  The patient got his back up again, angrily and loudly refusing to cooperate with the doctor on the other end of the phone.  When I got back on the line, the attending said, “Bill, based on that interaction, I don’t see how he could be described as competent.  He is going to have to go to the hospital.”  Based on that interaction, I had to agree.

My partner asked for a few police officers to come by to help us with the brawl that was about to ensue.  It was not going to be fun to wrestle a sick elderly man to the ambulance.  I was picturing him worsening, plus he wasn’t exactly one of the weaker elderly patients I’d ever met.  This was fixing to be a headache.  So I spent the time waiting for the police by calming the patient down again and chatting.  Once he was calm, you could see that he had capacity.  This guy wasn’t confused, he was an angry old man.  I think my partner saw the same thing.  She came up to me and said, “Bill, I don’t feel good about this.”

I didn’t either.  This was a clash between the ethical principles of autonomy (patient can decide what happens to them) and beneficence (we’re here to help people).  I was being asked to drag a man out of his home and force care upon him.  If he wasn’t competent to refuse, if he didn’t possess decision-making capacity, it would be okay with me.  But he had capacity and didn’t want anything that was about to happen to him.  I continued chatting with the patient more and he mentioned that he would be okay with going to his doctor at the clinic and his son could drive him there.  But he reiterated that he would not agree to visit a hospital.

I decided to call the biophone back and asked for the attending physician that I had called 10 minutes before.  I explained my point of view: “Dr X, I really don’t feel good about forcing this patient to go to the hospital.  I think he has capacity.  He is just a really angry old guy who isn’t interacting in a productive way.  I wonder if I could talk you into speaking to him again.”

“Well, Bill, I will try.  But I don’t see anything that could happen to change my mind.”  The doctor paused.  “What makes you think he has capacity when I am sure he doesn’t?  I don’t like being on completely different pages here.”

BAM!  This is the phenomenal question that made my heart swell with pride at my EMS agency and system.  Both the doctor and I were uncomfortable about being on different pages.  There was only one patient.  We should be interpreting the situation in similar ways.  One of us was wrong.  I am fully willing to accept that it is probably me, but I love it that a busy attending physician will listen to my point of view and consider it.  If there is other information that I didn’t have, was misinterpreting, or was miscommunicating we will get on the same page.  It is this process that protects us, our patients, and the system as a whole.  It is collaboration, with mutual respect, oriented toward doing the best thing for a patient.  The doctor is accepting my role as a patient advocate and respects the fact that my opinion may be correct.  I flat love it!

In any case, I explained what I was seeing that gave me the belief that the patient was competent to decide.  I explained that the patient came up with the clinic/son driving plan on his own, which to me showed that he understood his need for care and could make rational (if still wrong) decisions to get help.  This time, the physician agreed.  I had convinced him.  He had listened to me with a mind that was open enough for me to change it.  We stayed on scene to help the patient negotiate the appointment process, got someone he liked to stay with him and keep an eye on him, and made sure his ride was all set up for the appointment two hours later. 

It is certainly suboptimal that the patient wasn’t going to the hospital.  But patients are allowed to make bad choices.  I wish he had agreed to the ambulance ride and emergency department visit.  But what I want is immaterial with a competent adult who can choose for himself/herself.

The point of all this rambling is to illustrate how clear phone communication that includes open-mindedness, respect, and collaboration can protect the doctor performing the consult, the paramedics on scene, and especially the patients.  If you don’t work in an EMS system where you are trusted to form accurate decisions, expected to describe a situation completely and accurately, be responsible for backing them up and supporting them, and trusted to advocate for the right thing then you are not working in a good EMS system.  On the biophone, I need to be accurate, correct, and pretty much error free.  But if I am doing that, I am considered to be a professional caregiver who is worthy of respect and consideration.  Awesome.  

Oh, and never get on the phone with the airline consultation service. Nothing productive will come from taking that phone the airline rep is handing you.