February 16, 2014

My Easily-Broken Family Rider Rule

A few years ago, my partner and I were dealing with an elderly woman with chest pain.  I was driving that day, so I helped get my partner set up in back before we transported.  The patient’s adult daughter was in the front seat, because she was going to ride to the hospital with us.  After getting everything ready for the transport, I walked around to the driver’s seat and got in.  The patient’s daughter was drinking out of a Wendy’s cup.  Weird – where did she get Wendy’s?  I must have had a questioning look on my face because the rider said, “Oh, sorry.  I’m so nervous, I got cottonmouth.  What is this, lemonade?”

She was correcting her cottonmouth with my drink.  My drink.  Without asking.  Without shame or embarrassment.  She was surprised when I asked her to exit the ambulance immediately. 

I’ve had family riders steal objects from my partner’s and my bags.  I’ve had riders start fights with the patient in back.  I’ve had riders that turned out to be the bad guy that actually caused the patient’s injuries.  I’ve had riders who told me they were uninjured complain of neck pain upon arrival to the hospital.  I’ve had riders suddenly flip out and interfere with driving.  I’ve had riders listen to medics working in back say things like, “This dude dead.  What’s that coca cola shit coming out of his eyes?” (The medics didn’t know the rider was up front).  I’ve had riders ping the metal detector upon arrival to the hospital with their concealed pistol.

Thus, I hate to take riders.

I work in a good place that has no demanding policy about family riders.  Our policy is that riders are at the crew’s discretion.  My personal policy is: “No riders, sorry.  We’re not allowed.”  I’ve had too many riders not work out for me. 

But, like everything in EMS, there are certainly exceptions to my no-rider policy.  I despise if-then situations.  I hate not making a decision – it makes me feel like I am not in charge.  I am willing to accept the responsibility, so let me choose.  I will decide on the merits of each situation.

I always try to weigh a cost-benefit analysis with every decision.  I hate working around paramedics that live in a black and white world.  I’d hate to work in an agency that sets firm rules on this topic.  I start on the ‘no riders’ side of the fence, but there are always exceptions.  So let me work through the cost-benefit list in advance.

The costs include the fact that riders can become distractions to driving and patient care, they are another body that I am responsible for, they may be “secret patients,” they can be emotionally scarred from watching aggressive medical care, they may witness a call falling apart, they can steal, and they can be the perpetrator. 

One final big cost – patient confidentiality is ruined by having a rider in the bus.  This is the main reason for my no-rider policy.  Essentially every medical problem is of a personal nature.  I don’t need to be discussing how my bowel movements have been over the last few days with people listening – even my wife.  We ask about medications, drug and alcohol use, sexual activity, bodily functions, and other embarrassing topics.  It doesn’t embarrass us because we are professionals.  You will get more truthful answers if your exam, history, and care are performed in a private setting.

I try to avoid riders when:
  • The patient may become combative, like intoxicated, confused, or post-ictal patients.
  • The rider is intoxicated.
  • Emergency transports – by definition, these settings require a lot of focused attention and work.  I don’t like to add a potential distraction.
  • The rider was in the crash as well.  Too many get to the hospital as an uninjured rider and become a patient: “Yeah, my neck is killing me.”  Then I am the jerk who ignored the hurt guy.
  • Non-family, like acquaintances or co-workers.  I get the impression that most co-workers who offer to hang out at the hospital for a few hours are just busybodies who feel nosy.
  • Any patient problem is of a private nature, which is most of them.

On the allow-the-rider side of the ledger, riders can be legally required (as in the case of minor patients), they can provide information about the patient’s medical history and recent events, and they can be kept safer by riding to the hospital than remaining on scene. 

So, I will make exceptions to the no-rider rule for:
  • Parents of young children.  I try to not take riders of teenagers when I think the parents will get in the way.  I need truthful answers and parents can sometimes get in the way of that.  I also try not to take riders when I am dealing with critically ill children.  But as a father, I understand that there is no way I am stepping away from my kid to let a stranger deal with it.  Not happening.  So that is why I say ‘I try not to take riders…’
  • People in dangerous situations.  I won’t leave the patient’s girlfriend in a seedy neighborhood, at night, with no easy way out.  I won’t leave kids alone.  There are usually other options, like police or fire department help, but sometimes I’m in a hurry and it is faster to take the rider.
  • Helpless people.  I’m not leaving the patient’s wife of 50 years at home, when he is having a stroke and she is blind. 
  • The rider benefits me.  If a rider hits any of the list of benefits above (like they know a detailed history of events), then there is a benefit to me for taking a rider.

If I make the wrong choice, I will pull over, kick them out, and call the cops if need be.

The final important point is to not be an asshole about it.  I put on a friendly smile and explain, “Sorry, we're not allowed to take riders.  He is in good hands, and nothing bad is going to happen today.  We’re not using lights and sirens to get there, so you shouldn’t either.  As a matter of fact, he will probably be there for a few hours, so take your time before you leave.  We’re going to X Hospital, over at Main and First.  Do you know where that is?  Do you need a map or directions?”

Hopefully you work in a progressive agency like mine.  Make your own choice about riders, and do what you’d be proud to defend.


Andy W said...

You forgot to mention the front of the ambulance is our office and living quarters (especially for system status management crews) so I refuse anybody dirty, stinky, bedbug suspicious, etc.

Prehospital Wisdom said...

Completely good point, Andy. I am ashamed that I've been working days and forgot to include a good point like that…