Lazy EMS – Encouraging the RMA

I had an EMT friend call me the other day with a problem she’s having at work. After listening to her and being less than helpful, I thought that I’d share this with you and see what you’d all have to say about it. I’ll give you my advice to her, but I didn’t honestly have all that good of advice to give her. Let’s see what you think.

My friend who we’ll call her “Ann” even though that may or may not be her real name, is a former partner of mine. She’s a cool girl. She’s as much of the caring, kind, and competent EMT as you’d ever want in a partner and she’s also pretty fun to work with. I liked working with her and was sad to see her move away. I was happy for her when she got this BLS 911/Transfer job on a “big city” ambulance service, but she’s had some troubles there. Now, I’ve worked with her for a year as one of my regular partners and I know she’s good at what she does. I also know that the reputations of all of the ambulance services in this “Big City” aren’t all that stellar. Frankly, I’d take her word over theirs if I was pressed to answer a about it. 

She called me and asked my opinion on what she should do about a situation that’s developing with a new partner of hers up there in the big city. She explained that this guy is a know-it-all type who encourages RMA’s (refusals, Against-Medical-Advice, etc) on almost every patient. She says that he won’t touch anything unless it’s a true emergency and tries to dissuade every patient who he feels is beneath wasting his valuable BLS time on. She says that it’s reckless and that he does it to excess, even when it’s clearly not in the patient’s best interest in her opinion. She says that he rationalizes it by saying that the patients won’t pay their bills anyway, and that some of these patients are simply being a burden on the system in general and that he’s just doing his job.

And I can understand that… to a point. I mean, who among us has ever rolled their eyes as a drama-filled patient tries to overplay their conditions to get sympathy and a transport or simply doesn’t even try and expects a free ride to three hots and a cot… I get that. In fact, I see it all the time. It bothers me to no end… and yet I rarely, if ever, encourage an RMA.

Ahhh, this is SO much better than doing a report

In fact, there are only certain times that I ever will encourage a refusal… and that is when there is a clear benefit to the patient not be transported to an ER via ambulance. I will do this at times when the patient will be better served by something like an urgent care center, or by a quick trip to their primary care doctor. I’ll show up, provide a full and detailed assessment, and actually talk to the patient about their options for medical care. I’ll tell them that maybe the stitches they need would be done faster and cheaper at the Urgent care down the street than at the ER, or that their need for a simple x-ray or throat culture could be handled somewhere else. I’ll even tell them when I think they can save money and still be safe by being transported to the ER via private car rather than by my ambulance. I feel comfortable doing that when it’s clearly in the PATIENT’S best interest – NEVER when it’s in MY best interest. Even then, if the patient still wants to go via ambulance to an ER or is unsure that my option is the best option for them I transport them without complaint. It’s just safer for my career to do that. Ultimately, I’m not a physician and I can’t make the final legal determination on what’s best. Only the patient or a physician can do that and I am usually not the patient.

However, that’s not what Ann says this new partner of hers is doing. She says that he tries to defer every transport on the grounds that he’s lazy and then he writes very sloppy reports about the calls he refuses. She says that he’s been in trouble for this before and that while he was working at another service, he was actually almost terminated for this behavior.

I know the type of EMT he is… He’s the “So, do you want to be transported or what?” kind of EMT. The kind of EMS person who feels that he or she doesn’t ever respond to “Check someone out” and that only the patients that absolutely have to be transported to an ER for an “awesome” enough medical complaint are truly worth their time.

I hate those kinds of EMTs.

She is concerned for her job, her license, and her career while she works with this guy. She doesn’t want his bad behavior to get her roped into a complaint, lawsuit, or worse… she wanted to know if there was a way she could protect herself legally from his actions while she was working with him.

I went with my stock answer on this. Being an EMS supervisor myself, I asked her if she’d talked to her superiors about this. She said she had done just that, and it hadn’t gotten anywhere.

I wasn’t surprised.

Unfortunately for my friend, there’s just no reasoning with this kind of EMT. I’ve worked with their kind before and I know how painful one’s working relationship with these people can get when you force them to *gasp* do their jobs and take people places while treating them for whatever they say their medical complaint is. They tend to get growly at you when you tell them you’re having trouble hearing them over the sound of you not caring what they think. It makes lunch time a tenuous situation and totally ruins the Christmas party.

My next pearl of advice to her was to tell her to actually send a written letter to her supervisors, detailing her complaints and stating her concerns in writing. My thoughts would be that then, there would be a paper trail that shows she at least tried to do something about it. Unfortunately, I also had to warn her that it may end up branding her as a trouble-maker when the bosses realize that they now have a paper trail too, only they actually have to do something about it. They may retaliate against her instead.

Then I told her to CC a copy of the letter to the medical director, just for emphasis. It’s because I’m a devious trouble-maker myself.

Situations like this are all too common out there and they are the things that hold our profession back. Yes, I know that there are system abusers out there in patientville. We’re not going to fix that with our current system and really need to get more options out there for appropriate treatment pathways. However, putting people at risk by encouraging RMAs because you’re a lazy provider hurts our efforts by setting a bad precedent. Please don’t do this people. Take it from me. I’d never let you get away with it on my shift.

Does anyone else have any better advice for my friend Ann?


Also, it may be helpful to read this post: a primer on the people I call “Grumblemedics”

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  • Don’t know how secure Ann’s job is, but she could always plain and outrightly refuse to work with said partner. Just say no, kids.
    Or act in the patients best interest, always offer a ride to ED (in spite of what partner says)…takes guts to do that…but after a while, said partner won’t want to work with Ann either.
    Keep us posted!

  • Occam’s Razor time. Is there any reason why she just can’t tech all or more of the calls? Sometimes the best action is to just take charge instead of complaining (albeit complaining certainly has it’s merits, but sometimes you just have to stop banging your head).

    A for example. I was once (thankfully only once, I tend to really annoy these types of ‘coworkers’) was partnered with a guy who took the entire, “You have 20 minutes to clear a transport after reaching the destination” as “You have 20 minutes, if you finish early, just take a break with the balance of the time.” Sorry, I don’t play that game. I go to work to work and get a paycheck and consider a work ethic to be extremely important. Solution? When if I could reach the cab before he could, I just called us in as clear and he wouldn’t know any different.

    Similarly, the problem is him taking charge of the scene. Solution? Take it back. If he doesn’t want to tech these calls, then fine. He can help package and load the patient, drive, and transfer care. She can do the patient work, and if he doesn’t like it, he can go pound sand.

  • Anonymous

    I have a question for you related to this question. Let me start with a quick background. I am an EMT at a private EMS agency where we do both transfers and 911. I usually am working with a medic partner. I find that often on refusals, such as when we go to a house to help someone off the floor or similar situations, my partner won’t fully assess the patient, and does not do any paperwork on them (“Lift assist only, no info, no signature”). These always make me nervous, because what if the patient does have something wrong with them that we missed by not assessing them, or by not documenting the assessment if we did one. Now as the basic on the truck, I am consoling myself by saying that if the shit hits the fan, it will fall onto my coworker, the medic, but I know that might not be true. Oh, and this isn’t just one partner, as I have a different person every day, it is in the culture of the company to not do proper refusals.
    Any ideas?

  • Christopher Updike

    Chris I completely agree with your advice, and sympathize with Ann. I too have had partners like this in the past, and will most likely have partners like this in the future. I agree with flobach in the comment about taking charge of the calls yourself. I know its no fun to be the only person “working on the call,” but on that same token you are just as responsible for the patient’s care when your partner performs (or doesn’t in this case.)
    I would be cautious about the paper trail, namely because of the chance at being called a trouble-maker, but then again if the local workforce development, medical director, or state medical director got wind of a service terminating someone because they were trying to better patient care I’m guessing that service would be out of business very quickly. I have an idea of the service you are speaking of, and its important to remember that the bigger they are, the harder they fall. They aren’t immune to criticism, it just has to be given in a more political setting.
    I digress, the most important action Ann should take right now is stepping in and taking charge of the calls if she feels these patients need to be transported. Ultimately its her license, its her responsibility, and it may create turmoil at first, but maybe it will open the eyes of her partner into offering better patient care. As HappyMedic just discussed in his article about “EMS Anchors,” he made a comment about how these type of people can’t just be “cut loose to right our ship.” This EMT clearly needs some insight and possibly remedial training, if management won’t recognize it, maybe Ann’s new duty is to do just that: offer insight and remedial training.


    I had a similar issue with a partner. What I did was contact a supervisor and ask if I could talk to them privately and ‘off the record’ about my partner. If Ann is afraid to go ‘on the record’ and thinks she can go to someone ‘off the record’ have her do that at least. Also, have her keep a log of her own for the future. She’s putting herself in legal danger and she will need to back her actions up should someone decide to sue her partner and her service for negligence and failing to act under the duty to act laws.

    Now, the first thing I suggest is she talk to her partner with the laws in hand pointing out he/she is putting both their certifications and their livelihoods on the line with all the RMAs. Her partner is not a physician, he/she has a duty to act accordingly whether or not they believe the person is worthy of their time. This has serious legal and litigious ramifications!

  • Alsresq

    Ann needs to bring this to the attention of her supervisor, by not doing so she is placing the patient and herself in a dangerous position. Even if a refusal is signed it doesn’t relieve her obligation as and EMT to do what is best for the patient. If I were her I would immediately contact the supervisor in charge, describe what is going on before someone gets seriously hurt.

  • Rjstewart

    I’d give my supervisor a good and honest talk about why I feel this way. Then if nothing came of it, I would bring it to my union rep.

  • Lisa

    I know that feeling that your supervisor doesnt have your back.. The guy i work with went behind my back because he didnt like the report i type. So he took the patient name out of headquaters and wrote a another report and fax it to the hospital.. CAN anyone say HIPPA.. But my boss just slap him on the wrist.. While I ripe him a new a**hole… And he is still working here.. I said keep a book of everything that happens and sent letters to your boss anyway.. So when the shit hits the fan your cover..

  • RD code red

    I have another tack she could take… I had a few such partners. Using the example of a patient that wants to go, has every right to go… I would watch as this lazy bastid would try to talk them out of it. Heh. Well then at that point I’d chime in and talk them RIGHT INTO IT. nothing subversive or unethical, just a “better safe than sorry” friendly approach. After the call when he would whine that I shouldn’t have said what I did or that I was wrong to encourage the patient.. I said, ‘ok well then why don’t you complain to our boss that I made a patient go to the hospital and didn’t let you pressure them to RMA, see how that flies.”. Funny after that happened a couple of times said lazy bastid now no longer wants to work with ME. Problem solved in reverse And as far as to transport or not to transport, one has erred on the side of caution and everyone who wanted to go.. went.

  • Rich

    I agree whole heartedly w/ EMSFireFan and RD Code Red. First try to talk to your partner, if that doesn’t work, chime in while he’s trying to convince the pt and convince them to go. You may need to take the call over, however. If your an EMT and (s)he is a Medic, and the call is borderline or ALS, then once the pt is in the truck, you can use the infamous words “I’m not comfortable taking this call due to my certification level.” If that continues then you can talk to your supervisor and mostly your Medical Director (since it’s both (Your partner’s and yours) licences and your working under the MD’s licence). As a Medic myself, I have taken BLS calls in the past that my partner was trying to do a refusal.

  • RD code red

    After the fact I would certainly rather explain to someone why I DID take someone to the hospital, than why I DIDN’T. (Oddly I’ve used the same kind of logic when keeping medics etc.)
    Oh and Just a side note… I revisited the link/listing of this article on Jems’ Facebook page. The last comment is by an alleged EMT in which she outlines a scenario where she struck her partner in the face (and reached over a patient to do it). Despite the description of the patient having a positive response, her proud, ignorantly gleeful accounting of an incident where she acts abhorrently is one of the most unprofessional things I’ve ever read. I’m very surprised Jems has let the comment stay up there.

  • Dougww

    I think your advice is good, particularly the CC to the medical director. Refusing to work with this person might be a bit much given her newbie status, but a firm request to change partners might be better. Eventually Mr. “Give me Trauma or Let Me Sleep” is going to get burned by this behavior, and badly. She doesn’t want to be around him when it happens. I certainly hope they don’t retaliate against her, because he is definitely a problem waiting to become a disaster.

    Failing all of that, make him drive every day.

  • usalsfyre

    Sometimes doing what’s right puts you in the “troublemaker” category. Doesn’t mean it shouldn’t be done. I am curious if she’s tried the tack of talking to her supervisor about all the lost revenue from RMA’s that could have been transported vs the financial liability of leaving them at home and risking a lawsuit. Talking to their wallets usually gets admin types attention real quick.

  • TheEMSbrat

    My advice would be to talk to her partner and tell him how she feels and tell him why she feels the way she does. I would remind him of the duty to act laws and remind him about the dangers he is putting the patients in as well as the legal dangers he is putting himself, Ann and the company in. He should also be reminded that the needs of the patients should always come first and before his own needs. I would ask him why he is in this job if he does not like to do any work. I would ask him to rethink his priorities and motivation for being an EMT. I would also tell him that this issue needs to be dealt with and if he continues to do this, that she should talk to her supervisor and if that does not work then go to the medical directer. If this does not get her anywhere then request a meeting in writing with her supervisor, the medical director and the EMT in question. When writing to the supervisor and or medical director, she should be sure to state that she is not bringing this problem to their attention to be a troublemaker and be sure to express great concern the patient’s best interest.

  • Rhunic

    Whatever happend to having to call medical control to get approval for a refusal? I mean if he is trying to talk someone into not being transported, couldn’t you just call up the good old med control and tell them the situation and see what they want? I mean if you seriously think the patient needs the trip to the er, I don’t see why not to call. I understand not wanting to be labeled a “trouble maker” but 1:CYA!!!! and 2:You are a patient advocate, always do what is best for your patient and even if someone doesn’t like you they will still have to respect you for sticking to your guns. Remember your not the one with the problem, Mister Lazy-ass is. If your supervisors/managers can’t respect the fact that you play by the rules and expect your partner too as well, then it would be a good idea to find a different company to work for before you end up in court.(its not fun)

  • Since you’ve already stated that her partner is a “know-it-all” talking to him one-on-one probably won’t help, as he will probably dismiss the opinion of a lesser-ranking EMT. I think your advised course of action is probably the best, considering the supervisors are also being a bit thick-headed about this…

  • Daniel Gerard

    I was disgusted by your comment ‘In fact, there are only certain times that I ever will encourage a refusal… and that is when there is a clear benefit to the patient not be transported to an ER via ambulance.’ You aren’t any better than the EMT or paramedic who tells patients that do not need to go to the hospital in an ambulance…that it would be better or ok for them to go to a clinic…or that it was safe to drive him themselves or follow up with their doctor the next day…it isn’t contained anywhere in the national curriculum, and science has demonstrated that EMT’s and paramedics are poor predictors of medical necessity, you can find that in PubMed.

    If there are ‘certain’ times that you feel it is acceptable to ‘recommend’ to a patient that they can seek other options, show me where it says that in your treatment protocols? Tell me that your medical director or state EMS agency endorses this practice? Better yet show m where it says this is an acceptable practice in the National Standard Curriculum?

    PHYSICIANS struggle with this at times, and they are better educated and INDEPENDENT practitioners. You tell them how you can save them money?? Better served??? Policy decisions and OPERATIONAL decisions are best handled by OPERATIONS Managers and POLICY MAKERS.

    PLEASE PEOPLE DON’T TELL ME EVERYBODY DOES IT. If that is the case everybody is stupid. The reality of the situation is that you have not been trained how to do this, you don’t have a policy that regulates this practice, and your medical director, whose license you are practicing under, would have a stroke if he found out you did this.

    • Skip Kirkwood

      I’m with Danny completely on this one. There is research that shows that PARAMEDICS are wrong 25% of the time when they make “Who needs to go to the hospital” decisions – I can’t imagine EMTs are any better. 25% error rate is far too bad to be allowed. No surprise, since they spend 0 minutes in EMT or paramedic school on this process.

      You were called to transport. Your service gets paid to transport. How about you just transport, or move on to some other more rewarding career?