Your opinions on a run

[CPhT]

*This is being written from my point of view, as a student third rider aboard a private company basic rig* THIS IS A HYPOTHETICAL SITUATION AND HAS ABSOLUTELY NO BASIS IN REAL LIFE, AND ANY SIMILARITIES TO A REAL CALL ARE PURELY COINCIDENTAL.

While finishing paperwork from a previous run, a citizen knocks on the drivers window of the truck. Bear in mind, we're still sitting in the emergency lot at the hospital, it's dark, and this is the west side of Detroit.

Citizen: "Hey, can you all take my mom from this hospital to (other hospital on east side)? She had surgery about 7 weeks ago and isn't getting any better, and we want to take her to a better hospital."

Tech 1: "Well, we can't just go in and get her. She has to be released first, then we can take her wherever you want, but it still has to go through the proper chain of command. We have to take the call from our dispatch."

Citizen: "We're going to sign her out AMA so we can take her to the other hospital. She's been there before so we want to go back."

Tech 1: "OK. Here's our number for dispatch, and here's who you need to call. If you go through the proper chains, they'll send someone back out to get her and take her where you want to go."

Dispatch: Bravo 7, cleared at (west-side Detroit hospital), return to post at (suburban hospital 30 minutes away).

*29 minutes, 30 seconds later, as we're pulling into post*

Dispatch: Bravo 7, priority 3 at (hospital you were just at) for patient transport to (east-side hospital).

Tech 2: Copy priority 3, en route to (west side hospital).

*30 minutes later, we arrive to find the patient on a recovery floor. PT is late 80s/early 90s, female, 7 weeks post-op on open heart surgery. All patient-related medical questions are being answered by the family, as the staff is now refusing to answer any and all questions about the patient. Any questions are answered with either "I can't tell you because that's a HIPAA violation" or "She already signed out AMA, that's not our concern". When we arrived, the nurses were taking her off her IV, taking off her monitors, and even went so far as to take away her food tray.

After getting an initial impression of the patient, the lead tech used the truck cell phone to call dispatch for advice on whether this would be a call better handled by an Advanced rig, but we were told to handle it. We loaded the pt into the truck, took history and vitals, and started on the way to the new hospital. Turns out the pt has a hx of HTN, 2x CVA, 2x MI, all within the last 5 years. Her vitals were surprisingly normal. A/Ox3, P70, BP112/60, R18. PT was high as a kite because of her Fentanyl patch, but otherwise in good shape. Maybe it's just my newness, but both the tech driving and me were concerned that the long drive (30 minute transport) combined with the nature of the patient might have been a bad combination.

All in all, the patient made it to the other hospital just fine, and they were happy to take her. We were paranoid, but rightfully so.

Now for the learning experience:

1. Regarding what the first hospital was saying with HIPAA; since we were requested by the family, and we will be assuming care of the patient, were they wrong in withholding the patients information from us?

2. Would you, if you were an EMT-B, given the situation with the patient, have requested that an advanced truck take the patient? We were thinking that if the patient was on a monitor at the hospital, it would have probably been wise to do the same during the transport.

3. (Something the receiving facility mentioned) If a patient is released AMA, is it technically illegal for an ambulance crew to go into the hospital, pick up the patient, and take them to another facility? We were told that basically, it would have been more "legit" if the family had taken the patient out of the hospital, gone across the street to McDonalds, and called us from there, but that it's a grey area to actually come and get a patient from one hospital to another without medical orders to do so.

[HERBIE1]

I would definitely upgrade this patient to an ALS rig. 7 weeks post op and still in the hospital? The patient may have stable vitals now, but the nurse was just disconnecting all the drips, IV's, and monitors that may have kept this patient stable. I would also contact my medical control for direction ASAP. If the hospital staff is uncooperative, ask the family about PMH and medications. Assess the patient as if you would in their home or on the street. Is the surgical scar healing, or is it infected? Febrile? LOC? Arousable? Was the patient competent pre-op? Were there complications with the surgery? What type of open heart surgery- valve, bypass, etc? Why the Fentanyl patch? . I would be nervous about other issues- the patient is not competent, and what if the family is doing this against the wishes of the patient? Does someone have medical power of attorney? Does the patient have advanced directives?

I see no reason why an ALS crew couldn't take this patient to another hospital. Unusual? Sure, but not unheard of. Done a few myself back in my days on the privates, and no, I never received documentation/discharge papers from the hospital- other than the signed AMA release.Do lots of documentation, lots of witness signatures,etc, lots of involvement from medical control. As long as you are taking the patient to another medical facility- and they are stable enough for transport- and not home, I see no problem here.

[Richard B the EMT]

1. Regarding what the first hospital was saying with HIPAA; since we were requested by the family, and we will be assuming care of the patient, were they wrong in withholding the patients information from us?

I believe it to be wrong of the first hospital. The crew needs the information, as stated, for continuation of patient care.

2. Would you, if you were an EMT-B, given the situation with the patient, have requested that an advanced truck take the patient? We were thinking that if the patient was on a monitor at the hospital, it would have probably been wise to do the same during the transport.

I'd have made the request for ALS for the reasons stated.

3. (Something the receiving facility mentioned) If a patient is released AMA, is it technically illegal for an ambulance crew to go into the hospital, pick up the patient, and take them to another facility? We were told that basically, it would have been more "legit" if the family had taken the patient out of the hospital, gone across the street to McDonalds, and called us from there, but that it's a grey area to actually come and get a patient from one hospital to another without medical orders to do so.

No, it is a case of a fresh call, albeit an unusual pickup location, with a requested hospital destination different from where the pickup location happens to be.

I admit I might feel uncomfortable with the request.

[Kaisu]

I have real problems with the ethics of hospital personnel not giving thorough and professional transfer of care report. Citing a possible HIPAA violation is bullshit as you are/will be directly involved in patient care. That being said, whenever a patient leaves AMA, there are questions that need to be answered. There are patients that are impossible to care for - ones that refuse lifesaving treatment, are totally unreasonable and simply cannot be effectively treated. This is usually a symptom of a complete breakdown in patient/caregiver relationship and is normally not one sided.

The hospital washing it's hands of the patient is due to liability issues. A lawyer will make the case that although the patient had signed AMA, staff involving themselves in patient care after the signature assumes resumption of care by the hospital. Sucks but there it is.

If I am dispatched to this call, then I take the call and transport the patient (if appropriate). I agree with Herbie's post. Assess assess assess. If you feel that the transport requires ALS then request it. At the very least this patient appears to need ALS and, if unstable, possibly CCT.

Trust your instincts and the results of your assessment. If you feel hinky about it, call for higher level of care. Supervisors over-ruling your on scene assessment is despicable, but happens all the time.

[paramedicmike]

That's an awful lot of detail to have been purely hypothetical. Are you sure this call has no basis in real life?

If presented with this situation I would've done two things:

1. Called for a supervisor and done nothing until the supervisor arrived.

2. Called command and got a doc on the phone.

Hypothetically speaking, of course.

[Richard B the EMT]

Good points, Mike.

[CPhT]

That's an awful lot of detail to have been purely hypothetical. Are you sure this call has no basis in real life?

If presented with this situation I would've done two things:

1. Called for a supervisor and done nothing until the supervisor arrived.

2. Called command and got a doc on the phone.

Hypothetically speaking, of course.

In all honesty, had I been more than a student in this hypothetical situation, I would have definitely requested at least the advice of a supervisor. The originating hospital's position on AMA/ HIPAA aside, we could have treated the patient as any other IFT, read vitals on scene, recheck in the truck, recheck at interval until handing off to the receiving facility.

As it was, the lead tech requested that we at least kept an Alpha rig (advanced team) on standby in case things went south and we needed to do an intercept. Overall, the patient was easy going and was eternally grateful once we arrived at the receiving hospital. The only thing that I can see, as an outsider, that made the receiving hospital uneasy, was that we didn't call it in enroute and just sort of "showed up" with this patient.

I'm not familiar enough (shame on me) with HIPAA yet to know what my boundaries are, and when I should "raise a stink". The lead tech tried to make his case to the charge nurse, and the attending doc stepped in and shot him down.

My disclaimer regarding the "coincidental nature" of this post... that's just to protect the innocent. Names of pts, techs, companies, hospitals, and schools are withheld, call sign of the rig has been changed, and the situation has been modified sufficiently to represent something that was CLOSE to a real situation, but didn't actually happen. I want to learn from mistakes, so that I am not doomed to repeat them.

Thanks all for the advice/ comments!! Keep em coming!

Edited November 29, 2011 by CPhT

[paramedicmike]

My disclaimer regarding the "coincidental nature" of this post... that's just to protect the innocent. Names of pts, techs, companies, hospitals, and schools are withheld, call sign of the rig has been changed, and the situation has been modified sufficiently to represent something that was CLOSE to a real situation, but didn't actually happen. I want to learn from mistakes, so that I am not doomed to repeat them.

In the future, then, I suggest the Dragnet approach.

"The story you are about to read is true. Names have been changed to protect the innocent."

That way you're honest about it while still being vague enough to not out yourself.

edit: It posted twice.

Edited November 29, 2011 by paramedicmike

[Just Plain Ruff]

As a basic I would not have taken this patient. Cardiac drips and meds and all that stuff being taken off cold turkey is a recipe for disaster as any medic would tell you who's worth their salt.

I would have requested an ALS ambulance for transport. Even though nothing happened what if it would have, you have no history on this patient, the hospital staff are assholes for not giving you any help or info on this patient.

I would have definately called the receiving facility and given them the info that you had no info for them and the drugs were taken off the patient.

That doctor would definately have had a issue with this I am sure. (maybe not though)

This call sucked and you were doing the suckage because you were in the middle.

but you do the best you can with the info and circumstances given to you and when given lemons, make orange julius's.

I'll bet that trying to argue with the nurses at the original hospital would have been like trying to talk to a dining room table.

I would definately lodge a complaint to the administration of the hospital. I have done that several times

[CPhT]

I'll bet that trying to argue with the nurses at the original hospital would have been like trying to talk to a dining room table.

I would definately lodge a complaint to the administration of the hospital. I have done that several times

RE the nurses: I've had better luck with trying to teach my dog to speak Spanish. Ruffems, you've been to my area. Does the abbreviation SGH on W. Outer Dr. ring a bell as far as facilities? That's who we're talking about with the originating facility.

I did have the pleasure of listening to the attending ER doc at the receiving facility tear the floor nurse at the originating facility a "new one" via telephone. I was working on cleaning/re-sheeting the cot and getting paperwork signed, but the gist of the conversation was "how dare you try and use HIPAA to get around doing your job, and sending a high-risk patient out on the streets?". Pretty amazing to watch.

In the future, then, I suggest the Dragnet approach.

"The story you are about to read is true. Names have been changed to protect the innocent."

That way you're honest about it while still being vague enough to not out yourself.

I have no problem outing myself as a bonehead , I just didn't want to say anything potentially damning regarding the crew or the company. My crew was pretty awesome, and the service seemed pretty straight forward too.