Читать книгу Emergency Medical Services - Группа авторов - Страница 378

Experience shows that patient disposition after EMS contact can be less than straightforward. This is particularly true for patients who, at the time of evaluation by EMS clinicians, have a problem that has seemed to resolve, are not having any complaints, and lack an obvious acute pathology that requires intervention.

Unfortunately, patients experiencing syncope frequently fall into this category. Even patients with potentially life‐threatening causes of syncope, such as dysrhythmia, may have no complaints or physical examination findings during prehospital assessment.

So, what should we do with these patients? In many EMS systems, the only two choices are to transport the patient or obtain an informed refusal of care and transport. It is rare that syncope patients require specialty referral centers, especially if they are asymptomatic at time of EMS arrival. Usually, the rare causes of syncope that may require specialty referral (e.g., myocardial infarction, subarachnoid hemorrhage, and trauma after syncope) do not present asymptomatically. Therefore, for patients who agree to transport to the ED for evaluation, the closest facility is usually appropriate.

For the patient who refuses transport, the EMS crew must decide if the patient possesses adequate decision‐making capacity, including full understanding of risks, benefits, and alternatives. The explanation of the risks is perhaps the most important issue when considering the syncopal patient’s capacity to refuse transport. It is imperative that the EMS personnel have a clear understanding of the pathologies previously mentioned and can correlate those with the patient’s presentation. The level of training of the prehospital personnel will alter the ability to determine possible pathologies, the understanding of these, and the risks of not receiving evaluation in the ED.

The prehospital environment presents a complicated and dynamic practice arena. Thus, it is impossible to cover all possibilities regarding patient presentation and disposition. In the end, it is up to the EMS clinician to ensure that the patient’s final disposition is safe and in the best interest of the patient. Although the patient’s right to make decisions regarding his or her health care, assuming decision‐making capacity, of course, is paramount and must always be respected, it is equally important that all patients fully understand the potential risks associated with their conditions and the evaluation and treatment options that exist. “Autonomy trumps beneficence,” as the saying goes, but it is imperative that the patients be appropriately educated as to the potential risks of their conditions before they make their decisions to either seek additional evaluation and treatment or refuse further medical care.