Engine 30 and Medic 6 respond to their local shopping mall and find, Nancy, a 38-year old female complaining of tightness in her chest. Nancy is sitting on a sidewalk bus bench with her dog.

Bystanders tell you she seemed to get upset when she missed her bus and within minutes began complaining she wasn’t feeling well.

Nancy is visibly upset, but able to answer your questions appropriately. Her heart rate is 96, strong, regular and corresponds to sinus rhythm on your monitor, with a blood pressure of 156/88 and a respiratory rate of 28, non-labored.

The rest of her vital signs and physical assessment are within normal limits. She denies any medical problems except occasional panic attacks. Nancy requests and agrees to be transported to the hospital, which is 20 minutes away, but insists her canine companion join her.

She tells you he’s a “service dog” who provides her with emotional support and produces official-looking papers indicating her dog has been certified by Service Dogs of America.

Animals Supporting Patients

Many of our patients have significant debilitating emotional and physical conditions with complex treatment plans. Fortunately for thousands of people, like Nancy, their comfort can be enhanced with a variety support animals, and the crews in our scenario are faced with a situation that’s becoming more common every day.

We are all familiar with a guide dog with a leather-handled harness leading a blind person down our streets and safely navigating them through traffic and many other everyday obstacles. This human and canine partnership is no longer limited to just a blind person, nor those confined to a wheelchair. Today, specialized assistance is now available for patients with dozens of other conditions.

Several types of animals, but primarily dogs, are being trained in many new protection and detection arenas. For example, since canines have incredible senses, they can be trained to alert their human partner of an impending seizure.1 This partnership is extremely valuable and to be effective, it’s necessary for the dog to be with their human partner at all times.



EMS crews can’t request documentation to prove that a patient’s

dog has been trained, certified or licensed before accepting

it as legitimate service animal, and service animals aren’t

required to wear a vest or any other identifier.

Service animals not only provide assistance for physical conditions, but they often also provide emotional support. Our service men and women, and even police officers, firefighters and paramedics far too often are returning home from war or the violent streets right here in our own country, with varying degrees of post-traumatic stress disorder (PTSD).2 Many have received effective support and treatment by the loving support of a service dog.

These service dogs have been trained to perform specific tasks. For example, the service dog places a paw on the lap of a veteran suffering from PTSD after sensing a trigger is occurring. This type of canine-specific task training is recognized by ADA requirements that apply to paramedics and EMTs in the prehospital setting.

Federal and state service animal regulations are often broadly worded, which opens the door for people to label their pet as a service animal and pass themselves off as a person with a disability. This is unfortunate but a reality we must deal with in a professional, non-threatening manner.

The Americans with Disabilities Act (ADA) lays out a set of guidelines that clarify what is and what isn’t a service animal.3 No one would want to deny a person with a legitimate disability the ability to stay with his or her service dog, if possible.

Unfortunately, many people (and sometimes our patients) are abusing this valuable human-animal partnership, in order to take their pet with them to the store or hotel.

There are dozens of online options to pay a fee and with no credible justification; you can receive an official-looking certificate, identification card and tag for the animal’s collar. The ADA doesn’t recognize any of these types of programs and makes it clear these certifications don’t provide any meaningful service animal documentation.4

The slippery slope is knowing the ADA requirements and tactfully assessing each situation to determine a legitimate partnership and to identify when someone is gaming the system.



Service animals not only provide assistance for physical conditions,

but they often also provide emotional support.

Regulations & Responsibilities

The U.S. Department of Justice published revisions to ADA regulations on Sept. 15, 2010,

and implemented the requirements for both state and local governmental services and public accommodations/commercial facilities. There are three key provisions EMS agencies need to be aware of:

1. Beginning on March 15, 2011, only dogs are recognized as service animals.

2. A service animal is a dog that’s individually trained to do work or perform tasks for a person with a disability.

3. Generally, entities (including prehospital providers) must permit service animals to accompany people with disabilities in all areas where members of the public are allowed to go.3

Service animals are defined as dogs that are individually trained to do work or perform tasks for people with disabilities. Service animals are working animals, not pets. The work or task a dog has been trained to provide must be directly related to the person’s disability.

Examples of this type of work or tasks include: guiding people who are blind, alerting people who are deaf, pulling a wheelchair, alerting and protecting a person who is having a seizure, reminding a person with mental illness to take prescribed medications, calming a person with PTSD during an anxiety attack, or performing other important duties.3

It’s important to note that dogs (or any other animal) whose sole function is to provide comfort, therapy or emotional support do not qualify as service animals under the ADA. They haven’t been trained to perform a specific job or task, and therefore do not qualify as service animals under the ADA.3

There’s no federal legal obligation to allow emotional support dogs to accompany a patient in the ambulance. However, some state or local governments have laws allowing people to take emotional support animals into public places and those laws may also apply to ambulance transport.

Although you should always abide by the policies and protocols in place in your agency, best practice would be to try and accommodate an emotional support dog based on the overall situation and available options.

The decision to allow the patient and dog to remain together ultimately rests with the crew, and is based on the patient’s need and ability to control the animal, as well as the crew’s ability to transport the dog safely.

Transport Considerations

ADA requirements for stores, restaurants, public locations, hotels and even airlines differ from ambulance requirements. Under the ADA, state and local governments, businesses and nonprofit organizations that serve the public must allow service animals to accompany people with disabilities in all areas of the facility where the public is normally allowed to go.

Stores, restaurants, public locations, hotels, and even airlines are required to honor a much broader definition of service/emotional support animal. Ambulances are only required to accommodate service dogs, and ambulance crews can legally deny transporting all other types of animals.

When it’s not obvious what service a dog provides, only limited inquiries are allowed. Crews may ask two questions: 1) Is the dog a service animal required because of a disability? and 2) What work or task has the dog been trained to perform?4

Crews can’t ask about the person’s disability, request medical documentation, or ask that the dog demonstrate its ability to perform the work or task. Crews may not require documentation as proof that the dog has been trained, certified or licensed before accepting it as legitimate service animal. Service animals aren’t required to wear a vest or any other identifier indicating it as a service animal.

Prehospital crews can refuse to transport a service dog for any one of three primary reasons:

1. If the service dog will “fundamentally alter” the crew’s ability to provide lifesaving care;

2. The dog is out of control and the handler does not take effective action to control

it; or

3. The dog isn’t housebroken.3

The patient is required to maintain control of the service dog at all times. This means that the service dog must be harnessed, leashed or tethered, unless these devices interfere with the service animal’s work or the individual’s disability prevents using these devices. In that case, the individual must maintain control of the animal through voice, signal, or other effective controls.

When the patient is unconscious or in a condition requiring critical lifesaving treatment and the dog’s presence would compromise the care or safety during transport, it’s best to make other transport arrangements for the dog.

Note that the ADA doesn’t allow exclusion of a service dog for allergies, personal bias, fears or other reasons not covered above.3 The ADA doesn’t specifically define who’s responsible for the service dog should it not be transported, but best practices would certainly encourage prehospital crews to make every effort to reunite the dog with the patient as soon as reasonably possible (e.g., private car transport with family, friends, law enforcement, etc.).

Balancing Care & Legal Requirements

Every EMS system, public or private, needs to develop guidelines and logistical options to assist their crews in rapidly assessing alleged service dogs and the many other emotional support animals that crews may encounter.

The ADA defines what we must accept as a service dog, tells us clearly the limits we can take to make that determination and also when we can deny allowing the service dog to be transported with their owner.

These ADA requirements aren’t suggestions for you to decide to comply with or not, they’re legally binding and must be included in your overall treatment plan.

Any time a crew opts not to allow a service dog into their patient transportation plan, two distinct issues could result: 1) The patient’s emotional well-being may suffer and will likely result in additional anxiety; and 2) refusing a legitimate disability accommodation could have legal repercussions.

When considering the emotional support animal’s role during patient transportation (i.e., any animal that doesn’t fit the ADA’s definition of a service dog) it’s certainly legal to just say “no,” but consider if this is the best overall option for the patient. Think about it like this: If this were your mother or father, brother or sister, would you make the accommodation necessary to allow the patient the added measure of emotional support? Also, if the news media were filming your interaction, how would you want your decision to be portrayed to the public you serve? Would the Monday morning quarterback of public opinion say you were reasonable in your actions?

If you take the approach that every patient is a member of your family, why not make reasonable accommodations to include the animal in the transport arrangements-assuming it can be done safely, of course.

If you sense you’re being manipulated or tricked into allowing the animal to ride along, or if you see no benefit to the patient’s emotional or mental well-being, just say “no.”

Whatever you decide, be sure it’s in line with your agency’s policies. Alert and obey your chain of command as well as the receiving hospital. Be sure to document the presence of the animal, your decision to transport (or not to transport) as well as the rationale behind your decision. This will go a long way should questions or accusations arise.

Conclusion

As the Medic 6 crew prepares to transport Nancy to the hospital, they’re faced with the decision about what to do with her dog. It’s clear the dog doesn’t meet the ADA’s specific service animal criteria and the crew can legally deny allowing the dog to accompany Nancy to the hospital in the ambulance. But during their brief interaction with Nancy, they’ve been able to appreciate the special bond between her and her dog, and decide it’s best to transport them together.

Medic 6’s company policy allows the crew the discretion to decide when it’s in the best interest of patient care to transport a service animal as long as it can be accomplished in a safe manner.

The crew documents their decision and notes the emotional calmness the dog brings to Nancy. They also note that it’s obvious that her pet is a well-trained, obedient dog that clearly responds to Nancy’s direction.

During transport, the dog sits on the floor beside Nancy, where she is able to have both visual and physical contact. The emotional bond between Nancy and her dog helps make for a stress-free transport and the crew easily works around him during their follow-up assessments. Medic 6 advises the receiving hospital that the patient’s emotional support dog was part of the overall care plan and requests assistance during off-load.

Acknowledgment: The dog that appears in the photos for this article is Molly, a diabetic alert dog provided by

Arizona Power Paws, a nonprofit that provides highly skilled assistance dogs to children and adults with disabilities as well as education and continuing support for working assistance dog teams. Visit them online at www.azpowerpaws.org.

References

1. Seizure dogs. (n.d.) Epilepsy Foundation. Retrieved May 19, 2017, from www.epilepsy.com/get-help/staying-safe/seizure-dogs.

2. Krause-Parello CA, Sarni S, Padden E. Military veterans and canine assistance for post-traumatic stress disorder: A narrative review of the literature. Nurse Educ Today. 2016;47:43-50.

3. ADA requirements: Service animals. (July 12, 2011.) U.S. Department of Justice Civil Rights Division: Information and Technical Assistance on the Americans with Disabilities Act. Retrieved May 19, 2017, from www.ada.gov/service_animals_2010.htm.

4. Frequently asked questions about service animals and the ADA. (July 20, 2015.) U.S. Department of Justice Civil Rights Division: Information and Technical Assistance on the Americans with Disabilities Act. Retrieved May 19, 2017, from www.ada.gov/regs2010/service_animal_qa.html.