AMA should be DBU … (Don’t Blame Us)

Photo by Bernard Hermant on Unsplash

Nothing makes me appreciate my general luck so far more than walking into work each day. A sad case and situation at work recently got me typing. I’m thinking of a particular 6 year old patient with epilepsy and microcephaly; who can’t eat and has never spoken a word to his non-English speaking parents.

In one shift I saw him twice following suspected seizures. His parents don’t want to make any mistakes, so they try to follow instructions by their bay area pediatric neurologists to the T. And because it’s knee jerk for doctors and their receptionists to say “go to the ER if any concerns”, I got to care for this patient twice in a day, each visit by ambulance.

After some “just to be safe” blood and urine tests, and conversation with their doctors up north we came up with a plan and got the child’s medications redialed (twice).

A few shifts later, yet another ambulance visit by the same patient and parent for yet another possible seizure. The child was actually smiling this time and wide awake. But this visit stood out because of a new wrinkle. Because the seizure was brief and had resolved before paramedics arrived, mom didn’t actually want to come back to the ER again. The paramedics asked her to sign an AMA form as per their routine. However, she said she refused, because they said if anything bad were to happen it would be her fault.

I’m sure some things were lost in translation, but there are some lessons here:

  1. We live in a crazy medico-legal environment. Neither parents, nor paramedics, want “fault” and neither are to blame for that fear. This is our US healthcare soup. (ER doctors don’t want fault either, but the buck stops here. So we practice defensive medicine, and generally order far more than we would for ourselves. One way to miss nothing is to order everything.)
  2. If you sign AMA for something, you’re not a criminal and you won’t be blamed. You’re really signing that you won’t blame others. If we’re truly afraid, or if there is a clear life threat, then we generally don’t offer the AMA form.
  3. If you sign AMA and call EMS back later, they won’t say you’ve cried wolf too much. Some patients are transported to hospitals weekly if not more. The default for EMS is to transport. Plus it’s their bread and butter.
  4. I wish I knew all the financial implications of AMA, but I don’t. I also suspect it’s a sticky subject with insurance reimbursements. Maybe some of you have insights here?

In summary, EMS is a business and a moderately frightened one… like ER, like Pre-R, and like most folks in US medicine. No mistakes are acceptable so we hammer all nails with pneumatic nail guns.

So “just go to the ER if any concerns” may be a nice medical salutation. But use your judgment. If you wanna call Pre-R for some straight conversation ahead of time, feel free.

ER, Healthcare policy

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