An ALS crew was dispatched to a middle-aged man who called for shortness of breath.  The arrived to find a man who was tachypneic, with shallow respirations and reporting that he had a history of COPD and believed he was having a COPD exacerbation.  The patient reported to the crew that he did not want to be transported but wanted relief for his shortness of breath if possible.  The patient was evaluated on scene and had the following vitals:

Vitals: BP 142/76,  HR 102,  RR 27,  Sat 94%

The crew assessed the patient and thought he was having a COPD exacerbation administered a nebulized bronchodilator as well as placed an IV.  They gave IV magnesium was well as IV solumedrol and a small fluid bolus while the nebulizer was running.  After the treatment the patient was reassessed. 

Vitals: BP 138/74,  HR 90,  RR 22,  Sat 99%,  ETCO2 45mmHg

Patient reported feeling much better and had significant improvement in his respiratory effort.  The patient was still adamant about not going to the hospital.  He was able to walk around without difficulty breathing and could speak in full sentences.  The crew contacted medical control and discussed the case.  The physician they spoke with agreed that the patient had capacity to refuse so the patient was signed off, the IV was removed and the crew cleared the scene.

Highlights of the case:

Just because a patient does not want transport does not mean we should not treat them.

This patient told the crew right up front that he did not want to be transported but was still requesting treatment for his shortness of breath.  In situations like this, we should do our best to treat the patient as much as possible within the constraints that the patient is allowing.  Patients with capacity have the right to refuse specific treatments in addition to transport, however, we still have an obligation to optimize them as much as possible.  In the case of this patient, the crew gave breathing treatments to treat the bronchospasm and placed and IV for steroids to decrease the chance of the exacerbation from returning after they left.  While this led to a prolonged scene time for a patient who did not want transport, it was the right thing to do for this patient.

If there is a high-risk refusal against transport, we should involve online medical control.

Whenever there are concerns regarding patients having medical decision-making capacity to refuse treatment and/or transport, or it is a high-risk refusal, we should involve online medical control.  Sometimes having a patient talk to a physician (even if that physician says the same thing you have already said) is all it takes to convince a patient to change his/her mind and make a safer care decision.  Having a medical control physician speak with the patient also allows an additional person to assess the patient and ensure that they do indeed have the capacity to make their own decisions.  This crew had an appropriate conversation with the patient and determined that he had the capacity to refuse, but correctly involved medical control given it was a high-risk refusal.