I think the ER stole my patient

[fiznat]

Thread is worthless without clarification from the OP.

[HERBIE1]

I am utterly amazed this is even an issue. Unless the OP is trying to claim the hospital staff were imposters, THEY already had the patient. As was noted, how can he take over care from a higher medical authority, and then transfer the care back to that same hospital staff?

Our jobs are to get patients to a hospital, provide care at whatever level we are trained to, and to transfer that patient to the medical staff- hopefully in a bit better shape than when we found them. PERIOD. This is not about one company infringing on another's area, or "stealing" a patient in the field, ala "Mother Jugs and Speed:", this is about providing patient care.

There is no "turf" to defend, but I would guess someone's ego was bruised. Get over it. Hospital property, hospital responsibility and there are multiple lawsuits that certify that fact.

If they needed help with lifting, extrication, an extra set of hands for CPR, holding a door open for them, etc, then provide it, and document it appropriately.

Just. Wow.

[NYCEMS9115]

No problem in what the Hospital Healthcare Provider did. The patient is outside the hospital. The patient is on their property. You have a duty to act because you were dispatched. You should have assisted and take patient into the ER with the staffer. You would fill out the PCR as a transfer of care. You can't document as if you transported; it would be problematic if your company were to bill this. No need for signatures; just the name of the In-hospital Care Provider and note that you assisted him/her to take patient into ER. According to your story; you didn't document. This is a QA/QI issue...

Ex.(If this is what happened) U/A found pt IFO Jane Doe Mercy Medical. A Staff RN with a hospital stretcher onscene. As Per RN John Doe, he want crew to assist in placing pt onto stretcher because the ER were aware that the patient was coming in. Pt appeared lethargic; difficult to arouse. Noted AOB and pt had poor hygiene. Bystanders found pt there and called 911; one stated he ran into the ER to alert a staff member. No injuries apparent. Pt was incontinent with urine. Crew assisted RN with picking pt up off the pavement and placing pt onto gurney. Due to the instructions of the RN and the ER being 50feet away; PHC assessment and care deferred. Care taken over in ER by staff...

NYS EMS Disposition Code: 004

NYC EMS Disposition Code (10 Codes): 10-94B (BLS)

Of course this just my opinion; I wasn't there. I do respect your passion in protecting your area from "enemies"; foreign & domestic. Not making fun. That's how NYC EMS was in the 80s (so I've heard from older EMS Care Providers), 90s (I can only tell you about the last half of the 90s), & 2000s... Too many hitters were good for the Employee but bad for the Employer. Hence, bad for the Employee, if Employer closed as a result. "It has happened before and it will happen again. The question is: When?" Armageddon

Had to add a comment....

Edited June 8, 2011 by NYCEMS9115

[DwayneEMTP]

Yeah, I truly do get everyone's point. Perhaps I read more into this than anyone in fact, but I was trying to take a devil's advocate, 'what if' stance simply for the mental gymnastics it might provide.

Fiz is partially right, that there isn't enough information. Wrong, in my opinion that this thread is useless. I think it's been a very valuable thread if for no other reason than a bunch of hard headed providers have shown enough respect to debate each other. I've learned a lot about the opinions of other providers from different places and levels from their responses here.

So for me, this CAN be a no brainer. I show up and there is a gurney with some white coated folks talking to a patient not far from the ER doors. I help them load and strap the patient and away they go. I report a 'no contact, no medical needed' and be glad I got another call that didn't require me to decon the entire truck. I don't see the abandonment here if a higher level of care has already made contact.

Now, bump them back 15 seconds, so that I've made contact, have begun my interview, and the level of provider becomes very significant. Is the right thing to do to turn this patient over to whoever is going to get them through the doors fastest the RIGHT thing to do? Of course it is. But what happens when this patient is taken indoors, assessed and found to be having a life threatening MI, he's left with deficits, calls his lawyers and then my boss' lawyer wants to know why I handed an active MI over to two security guards with a gurney at the hospital? We all know how that story will end, right? How far will 'doing the right thing' go in covering my ass?

Hopefully most know that I've never been, and continue not to be a cover your ass first provider. The thing that stuck in my craw here, and being a medic instead of an in hospital provider is perhaps the reason that the Doc and I see this differently, is the comment, "you can come in and get the information you need." Though his, "your missing my point' comment certainly comes off as territorial and a bit arrogant, the previous statement seems to say, "Fuck you and your obligations, you're just driving the ambulance." I would not be offended by that as a medic, but would certainly get my back up if I thought that the ER's arrogant attitude would/could lead to me getting jammed up and being unable to provide for my family.

It would be nice to have the full story. I've not been offended by any comments, but was disappointed that there seemed to be no effort to try and flesh this issue out for this kid. (I say 'kid' as the presentation sounds younger, though I have no idea how old s/he might be.) Most of the important answers I've ever been given in my career were received because someone was smart enough to know what I needed to hear despite my not being smart enough to know the right questions to ask.

Maybe what it boils down to is who actually made contact first? If the OP was dispatched to this call, then s/he had a duty to act. If he in fact made first contact then he had an obligation to transfer care to a higher level of certification. If he was dispatched, and if he made first contact, and if he doesn't have a significant amount of experience, then I can easily see where this call would be confusing for him. Was this a complicated situation? It appears that it may have been for him...so it doesn't really matter how black and white it was to everyone else, does it?

I'm back to doing remote/clinical stuff now, which always tends to make me feel like my whole crews mother...it's likely in that spirit that I'm making a much bigger deal out of this than needs be...but that's ok...I can take it... :-)

Thanks for your thoughts everyone. Doc, sorry for the snotty tone in my response to you. It was meant to be kind of tongue in cheek aggressiveness but doesn't read that way to me upon review. You are a gift to us here...I certainly had no reason not to take the time to phrase things differently than I did.

Have a great day all! I look forward to your thoughts!

Dwayne

Edited to ad a missing word. No significant changes made.

Edited June 9, 2011 by DwayneEMTP

[Happiness]

dont know how it works there but here if the pt is out of the building it's a EMS call......

[ERDoc]

Dwayne, it's all good. I like getting called on things, it makes me think a little more about what I said. With a forums full of type-A egomaniacs like we have here, it's going to happen. Sometimes getting the right frame of reference on a comment is hard when it is written. I took the comment from the ER people in the OP as to say, "You can have any info you want, but let's get this guy inside first and do what we need to do to take care of him." In your MI scenario, would it make a difference if you had security, the entire cooking staff or a cardiologist? No one is going to be able to do anything for him out there. I think the only time that might change is if he's in cardiac arrest. You (as in the EMS crew) might have a more accessible monitor/defib. In that case, spark him up in the parking lot and do what you can.

Happiness, here in the US we have this wonderful government mandate called EMTALA that basically says that anyone with something like 250 yards of an ER entrance is the hospital's responsibility. This came from a court case where hospital staff refused to cross the street the hospital was on to help someone because they thought they would be in trouble for leaving hospital grounds (so the urban legend goes).

Edit: Comment to Happiness added after I originally posted.

Edited June 9, 2011 by ERDoc

[DwayneEMTP]

...In your MI scenario, would it make a difference if you had security, the entire cooking staff or a cardiologist? No one is going to be able to do anything for him out there...

I wouldn't have made any difference to this or most other patients in the moment, and in fact might be to his benefit to have someone that wasn't likely to stay and play outside of the doors of the ER, but what happens in hind sight? When things go south what happens to our OP when the legal questions begin?

If you turn to the first EMS uniform you see for your new arrest in the ER (as has happened to me on more than one occasion) and ask them to intubate while you run the CODE, what happens in hind site when it turns out that the basic, who appeared to be a medic, that you gave that responsibility too damages the airway and causes permanent damage? Are you later covered because you claim that you were trying to do what you felt was best, and most prudent for the patient or do you get your ass handed to you?

If I hand this patient, assuming I started my interview even a few seconds before the stretcher gets there, over to the people with the gurney and they drop him, what then happens when he's sues the hospital, ambulance company, etc? I have no idea, to tell the truth, but I find the question interesting...

People in scrubs next to a gurney does not a higher level of certification make...at least in theory. Only two times before have I been challenged on scene by someone claiming to be an RN. The first turned out to be a volly basic that was offended because I didn't KED a trauma before extrication but was afraid she wouldn't be taken seriously if she admitted who/what she was, and the second was a volly basic that had been taking care of her sick mom for several months and was confident that she knew everything an RN knew based on that experience. But in each case, had I conceded without delaying care to have the 'prove it' argument, I'm confident that the misconception would not have added ballast to my legal defense.

Again, I know I'm taking this down the "if a pregnant woman gets decapitated in a car accident is it ethical to do a medic level C-section to save the baby?" route...and that can be tiring for many, if not most, but the what if's are more educational and entertaining than most actualities in my experience.

Hell, I think that this turned out to be a really, really good thread. It's unfortunate that the OP didn't continue to participate.

Dwayne

[island emt]

I think the point is his not being respected on the street, in 'his' territory. Plus, having been dispatched to the call, he's got a duty to act and to advocate for his patient,

Dwayne

But thats the issue here dwayne, The pt is on hospital property and really never was his pt. When he arrived the pt was already being taken care of by hospital employees. Thus EMS has no duty to act even though they were called by a lookie loo with a cell phone.

Maybe he has his knickers in a knot because the hospital staff didn't defer to his superior medical knowledge, but take an open eyed look at the info given!

Edit to add:

There are cases where we were called to a local Emergency Room canopy area to package and extricate a pt that had CC of severe back pain from a fall and then had been driven to the ER by a family member.

There were already hospital staff on scene and had requested us to provide the equipment & expertise in removing the pt safely from a vehicle. Outside their field of knowledge and they deferred to EMS experience and knowledge.

Edited June 9, 2011 by island emt

[Just Plain Ruff]

Dwayne, it's all good. I like getting called on things, it makes me think a little more about what I said. With a forums full of type-A egomaniacs like we have here, it's going to happen. Sometimes getting the right frame of reference on a comment is hard when it is written. I took the comment from the ER people in the OP as to say, "You can have any info you want, but let's get this guy inside first and do what we need to do to take care of him." In your MI scenario, would it make a difference if you had security, the entire cooking staff or a cardiologist? No one is going to be able to do anything for him out there. I think the only time that might change is if he's in cardiac arrest. You (as in the EMS crew) might have a more accessible monitor/defib. In that case, spark him up in the parking lot and do what you can.

Happiness, here in the US we have this wonderful government mandate called EMTALA that basically says that anyone with something like 250 yards of an ER entrance is the hospital's responsibility. This came from a court case where hospital staff refused to cross the street the hospital was on to help someone because they thought they would be in trouble for leaving hospital grounds (so the urban legend goes).

Edit: Comment to Happiness added after I originally posted.

Yeah Doc on that EMTALA thing. Remember this was 16 years ago

I met it head on and it ended up really causing a rift between my employer and the hospital.

had a call where a 12 year old had been hit by a train. Massive head injury, brain matter showing, but still breathing, he was 2 blocks from a level 2 trauma center. I called that trauma center and said we were coming there. They refused him, and said to take him across town to the level 1 pediatric trauma center, a 30 minute drive. I asked if they were kidding and they said no.

Ok, so I called a helicopter and had it come to the refusing hospitals helipad and land to take this kid to the peds center.

We pulled onto the parking lot, waited for the helicopter and I intubated the kid, lines and all that. 10 minutes pass.

As the helicopter was landing a nurse came out and said to bring the patient into the hospital. She said that since we were on their property he was their patient. I said, "You refused him so I'm doing what your doctor said to do and getting him to children's" She said no he is our patient now. I said I'm not giving him up to you becuase the helicopter just landed" I asked how far out was the trauma team and she said they hadn't called them yet. I said he's going to childrens.

Well needless to say the doctor was pissed. I was mad because the hospital staff was nearly refusing to let me put the kid on the helicopter.

The hospital filed a formal complaint, my company responded with all the glamour of a employer who backed the medical decisions of it's employees but they said from now on if this happens again, cancel the helicopter and go in the ER, let them take care of the kid.

In the end, he made it to the childrens facility. He did not fare to well but he did not die. I think there were some CNS problems but I believe he is still alive and he should be in his late 20's or so.

Was that because I made the wrong decision to get him to the level 1 childrens trauma center, I don't know, I do know that when he got there an entire trauma team was ready for him and the flight was only 11 minutes from the one site to the other, whereas the refusing facility had not called a trauma team in and the team would have taken 15-20 minutes to assemble.

My medical decisions or judgement was never questioned, but the issue that was at hand was that the hospital said that once we were on their propterty I needed to bring the patient inside. I disagreed as well as my employer also disagreed.

What saved us on the EMTALA complaint was that I was using a secured helipad that the hospital had on site for a landing zone only. I was not utilizing their property any other way. AS a matter of fact I wasn't even expecting a response from the hospital. I even told them I would be calling a helicopter and having it use their helipad so they needed to alert security and the person on the other end of the radio at the refusing hospital said they would call security.

Would I do it differently, nope, a secured landing zone is much better than shutting down a street and landing the helicopter on the street in my opinion.

My company was the star in all this, they could have sided with the hospital but they didn't. they sided on my side and ever since AMR bought them, they haven't been the same.

[usalsfyre]

Ruff, EMTALA covers that situation specifically, as you noted. If the hospital choose to try to intervene in this case, I'd probably tell them to take a flying fornication at a rolling donut and get out of my truck. We can deal with the specifics later, including forwarding them a copy of the applicable EMTALA regulation later.