The author would like to thank EMT student Tobias Miller for submitting the following scenario for this month's column.

   You're an EMT student, and today's your first ride-along. You've never been in an ambulance, and you're nervous about that. You show up 30 minutes early, and a supervisor greets you politely. She's coming off of a 24, and she obviously has plenty of other things on her mind, but she shows you the coffee, gets you a release to sign, and then takes the form and shows you around the station. She points out the ambulance to which you'll be assigned and suggests you wait in the dayroom for your assigned crew.

   Before you can even sit down at the table another crew, Travis and Jeannie, get toned for a lady complaining of difficulty breathing and Travis invites you to join them. You hop in the back of their unit and buckle up, and they're all business. They're obviously comfortable with a gazillion or so panel switches and instruments, and they integrate themselves casually in a jumble of radio traffic that seems totally unintelligible to you. By your reckoning, a 10-minute response goes by in about 12 seconds. Now they're pulling up behind an empty engine idling in front of a small residence.

   Inside, you encounter a blue-haired woman in her 80s. Her home is immaculate and meticulously arranged. Her meds are on the little table next to her recliner in a one-week Tupperware organizer. She's complaining of chest pain, not shortness of breath, but now that you've arrived, she's not so sure about that, and she can't seem to make up her mind about going to the hospital. The exam, vitals and ECG are unremarkable, but she has this sense of dread, like something bad is happening, and that bothers you a lot more than anyone else. The crew is tired, and their patience soon runs out. They haven't run a 12-lead, their physical is cursory at best, and you're afraid they're blowing her off. They do offer to take her to the hospital, but she leaves the decision up to them. They opt for a signed release and an offer to return.

   Q. This woman lived alone. I believe her husband had died, because I noticed a photo of her with a man about her age. She seemed very embarrassed about calling 9-1-1, but she was complaining of left-sided chest pain radiating to her left shoulder, and she had this sense of dread. On top of it all, she was worried about getting home from the hospital. I wanted to tell her that the chance of dying is more important than a taxi fare and that hell, I'd come and pick her up, but I couldn't really do that. I was a student on a ride-along and didn't want to make the medic look bad.

   A. You sure you're a beginner? These are good instincts. Actually, there's some disagreement about whether to "get involved" in people's lives off duty. Personally, I think what you're suggesting is a very decent and reasonable form of advocacy. There's nothing wrong with it, as long as you don't make a big deal out of it in front of the crew. But under these circumstances, I think you're right. As a guest, I don't know how you would pull it off gracefully.

   Q. This lady had a journal documenting everything about her meds and the dates of everything. She was extremely embarrassed for calling us. I think that having control was very important to her, based on how she kept her house, and it seemed to me that she felt by calling us she had risked losing control. But shouldn't the crew have been more aggressive about getting her to a hospital?

   A. Maybe, given only this much information. But for one thing, we're not machines. None of us is perfect, and we all get tired. For another, you will meet some people who try to scare everybody into going to the hospital, whether it's clearly indicated or not. I think that's just as wrong as blowing people off. There are many EMS administrators who have tried to take their crews' judgment away from them. That's probably the worst mistake of all.

   Q. In the end it was decided this woman would see her PCP the following morning. I felt bad about leaving her. I felt like a piece of her was inside me now, because I cared about her. Unfortunately, the call was over.

   A. Thank you for that! But remember, this was just one call. You may run more than a thousand a year. Try to see yourself as a long-distance runner, not a sprinter. And feel welcome to question those ahead of you. They may have good reasons for the things they're doing.

   Thom Dick has been involved in EMS for 39 years, 23 of them as a full-time EMT and paramedic in San Diego County. He is the quality care coordinator for Platte Valley Ambulance Service, a community-owned, hospital-based 9-1-1 provider in Brighton, CO. Thom is also a member of EMS Magazine's editorial advisory board. Reach him at boxcar_414@yahoo.com.

   EMS Reruns addresses dilemmas in EMS. If you think of an example, send it to us. If we choose to publish your dilemma, we'll pay you $50. E-mail Nancy.Perry@cygnusb2b.com.