A half-assed contribution

Disclaimer: I wrote this essay for an ethics assignment a few days ago. It was a throw-away paper, so I probably put less time into it than I would have put into a real blog post. I don't even know exactly what the hell I'm talking about by the end, but if you have some time to kill, you might find this interesting.

Our last patient of the day was a middle-aged gentleman with terminal lung cancer. He was being discharged from the hospital back to his home to begin hospice care, where he would likely die within a few weeks. He needed a constant supply of high levels of supplemental oxygen just to stay conscious, but when we entered the room, he smiled and waved.

I was working as an Emergency Medical Technician (EMT) for a small, private ambulance company and we were dispatched to transport this patient to his home. This trip would likely take close to an hour, but long-distance transfers were common for our company. However, when we reviewed his chart and noticed the amount of oxygen this patient would require, my partner and I realized we did not have enough on the ambulance that day to make the trip. We called our supervisor on the radio to give him this news, and he informed us that it could be another hour before the next available ambulance could get to the hospital. To our surprise, we were then advised to transport the patient anyway, while giving him less oxygen than he needed.

With this case, I can identify a conflict between patient care and business. First, with patient care, we were being asked to place the patient in a situation that could easily have been harmful to him. However, in terms of the business, it was likely that our superior had feared that delaying this patient’s transport for another hour would have reflected poorly on the company, which could have jeopardized future business with this particular hospital.

My partner and I were in agreement that it was simply too risky to transport this patient with the limited supply of oxygen we had on-hand. By knowingly placing the patient in a potentially dangerous situation, we would have been violating our professional ethics as EMTs, as well as our moral standards as human beings. In addition, we clearly would have been acting under negligence and could have faced legal repercussions if the patient had suffered any injuries. For these reasons, it was an easy decision to refuse to transport the patient and request that our supervisor call the next available ambulance.

Though I was taken aback by my supervisor’s request, I was also able to see the issue from his point of view. Like the operator of any small business, his top priority is the company. As a small business, his company must remain competitive with larger companies. Consequently, a single contract with a single hospital comprises a larger percentage of the total revenue earned. In an economic sense, a single contract is more valuable to a smaller company than it would be to a larger company. This is a reasonable business model for most companies; however, there are many more ethical issues at stake when the product being sold is patient care.

At our patient’s bedside, it was clear to us that we could not transport him. As EMTs, we had been trained to think with protocol in mind, and to always remember the legal consequences of negligent action. I do not know of a single EMT, paramedic, or physician who would have made a different decision than we did, and even our supervisor later admitted that he had been hasty and careless in his handling of the situation. This situation was unfair to everyone involved: we were asked to knowingly endanger a patient, and as a result, we were forced to stand up to our supervisor and put our own positions as employees on the line. Even if we had agreed to transport the patient, he would most likely have preferred to wait for the next ambulance.

Though I have never operated an ambulance company and have no experience with medical administration, I imagine that balancing business and medicine is a formidable task. As a former EMT and current medical student, I have been trained to think of the patient as priority number one. But medical administrators have to balance patient care with the demands of the business; if the company suffers or fails, patients may be negatively impacted as well.

So how is this balance determined? In the case I have described above, it might have been useful to have a third party mediator who could look at the case from both my perspective as an EMT and my supervisor’s perspective as the company operator. From my perspective, the refusal to transport the patient put him in no additional harm, but did have the consequence of placing me in an uncomfortable position with my supervisor. From my supervisor’s perspective, my decision may have somewhat tarnished the ambulance company’s reputation as a fast and reliable provider of care, but in the long run, it likely protected the company’s reputation as a safe provider of care. It would have been helpful to have a third party mediator who could have identified these issues and presented them to both parties.

I believe that the best patient care is delivered when both the healthcare provider and the administrator has a basic understanding of the issues that the other party faces. It is easy as a healthcare provider to only think of the patient in front of you and forget about all of the other hidden elements that contribute to (or detract from) that patient’s care. As a newcomer to medicine, I hope that there will be communication between the healthcare providers and the administrators wherever I decide to work in the future. If I do not get involved in medical administration myself, I can only hope to have the opportunity to learn enough about it to begin to see these hidden elements, and to use this knowledge to the advantage of my patients.