Your opinions on a run

[Kaisu]

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.

And pretty amazing to read about too! Thanks for that.

[HERBIE1]

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.

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.

Good for that receiving ER doc, but I believe the originating facility was LEGALLY within their rights to wash their hands of the patient. I suspect they threw out HIPAA simply because citing only liability concerns would have been a crappy thing to do. Clearly there are moral and ethical issues at play here, but witholding paperwork- then more importantly the receiving hospital would not have the benefit of any current lab/procedure/exam results once the patient arrived- they would be starting at square one until they could get a hold of the PMD and treating MD's directly.

[romneyfor2012]

Unfortunately, the hospital was legally right, but could have handled it differently. Crapmagnet is right, the family put the first hospital into a bad situation.  Once they engage in giving report or continuing any further care, they are setting themselves up for legal problems and an EMTALA violation for an illegal transfer to another facility.  

This type of call happens frequently, although it is usually an ER patient who gets mad because the wait is too long or they did not get the pain med they wanted, and now want a taxi ride to the next ER.

You did not state what kind of drips/meds were running, 7 weeks post surgery the patient could just be on an IV with no meds, but if meds were being infused you would definitely be correct to request ALS.  The cardiac monitor use in the hospital does not necessarily make it an ALS call, as many patients are monitored via telemetry that do not require EMS, she may well have just been monitored because of her age and history, but again if your gut says "ALS", it is better to be safe than sorry.

As far as picking up a patient in the hospital, it is no different than anywhere else, IF the patient demands a transfer.  I always check with the staff to make sure, as we have had patients call our dispatch directly without involving the nurses, so you want to make sure the AMA or transfer paperwork is complete before leaving, and that the patient knows what risk they are putting themselves in.  

Before you file any formal complaints, you better clear it with your boss, as that could cause your company to lose the contract, and that would most likely get you fired.  I am not suggesting it get swept under the rug, but there are many things regarding this situation that you do not understand, so it would best be handled manager to manager.  And in this economy I doubt you want to be an unemployed EMTB; I know too many medics who lost their job because they reported a nursing home to the state over things that seemed like a big deal at the time, but were not in retrospect.  An example:  Go to pick up patient for fever, noted patient had nasty bed sores.  EMT assumes nursing home has not been treating and turning the patient properly, files a complaint with the state.  State inspectors come in to investigate.  What the EMT did not know was the patient had only been in that facility for 10-12 hours, and got those bedsores at home.  But the state's surprise inspection was not pleasant for the facility, as they always find something wrong when they come out for a complaint inspection.  Just like if I did a surprise inspection of most people's ambulance/station I could find some violation somewhere.

Edited November 29, 2011 by romneyfor2012

[CPhT]

Unfortunately, the hospital was legally right, but could have handled it differently. Crapmagnet is right, the family put the first hospital into a bad situation. Once they engage in giving report or continuing any further care, they are setting themselves up for legal problems and an EMTALA violation for an illegal transfer to another facility.

This type of call happens frequently, although it is usually an ER patient who gets mad because the wait is too long or they did not get the pain med they wanted, and now want a taxi ride to the next ER.

You did not state what kind of drips/meds were running, 7 weeks post surgery the patient could just be on an IV with no meds, but if meds were being infused you would definitely be correct to request ALS. The cardiac monitor use in the hospital does not necessarily make it an ALS call, as many patients are monitored via telemetry that do not require EMS, she may well have just been monitored because of her age and history, but again if your gut says "ALS", it is better to be safe than sorry.

As far as picking up a patient in the hospital, it is no different than anywhere else, IF the patient demands a transfer. I always check with the staff to make sure, as we have had patients call our dispatch directly without involving the nurses, so you want to make sure the AMA or transfer paperwork is complete before leaving, and that the patient knows what risk they are putting themselves in.

Before you file any formal complaints, you better clear it with your boss, as that could cause your company to lose the contract, and that would most likely get you fired. I am not suggesting it get swept under the rug, but there are many things regarding this situation that you do not understand, so it would best be handled manager to manager. And in this economy I doubt you want to be an unemployed EMTB; I know too many medics who lost their job because they reported a nursing home to the state over things that seemed like a big deal at the time, but were not in retrospect. An example: Go to pick up patient for fever, noted patient had nasty bed sores. EMT assumes nursing home has not been treating and turning the patient properly, files a complaint with the state. State inspectors come in to investigate. What the EMT did not know was the patient had only been in that facility for 10-12 hours, and got those bedsores at home. But the state's surprise inspection was not pleasant for the facility, as they always find something wrong when they come out for a complaint inspection. Just like if I did a surprise inspection of most people's ambulance/station I could find some violation somewhere.

That's good food for thought. I really appreciate hearing that side of things too. I have no intentions of taking up grievances or complaints with the hospital, or anyone for that matter. I think the lead tech I was riding with did everything in his power, as did the other tech. The family was demanding better care, and we were simply the "middle-men". I would hope that the staff at the hospital were acting in the patients best interests and not acting out of spite for the patient and/or her family. The attending Doc at the originating hospital was very condescending to the family, as well as our crew, but it's nothing outside of the ordinary (sadly).

With that run, I think I may have just had my first lesson in "shut up, load up, and keep your fingers crossed", with the realization that the patients level of care increased 10-fold by going to the other hospital.

[Richard B the EMT]

Perhaps I read this too quickly, and missed the detail, but was the receiving hospital aware they were going to get the patient in the first place? Or, did the crew just "show up" with the other hospital's Against Medical Advice patient transfer?

I am aware some areas of the US have policy that all patients have to be called in as a "Notification", so the ER can set up accordingly, or even advise the inbound crew of what room the patient is being direct-admitted to. My own FDNY EMS only calls in "Notes" when the crew deems it of medical nessesity.

[Bernhard]

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

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

Really?

Here, we would have the power to decide ourselves. Correct way here would be:

1. Notifying dispatch about the request and getting their acknowledgement to handle the transport or giving the details to have them organize another ambulance in case they need mine for something else. In this case, the following would be the task of the other crew.
   
2. See, if the patient is released by the hospital (paperwork/AMA signed). They have to, if the patient wishes.
   
3. Making sure, that the receiving hospital is willing to take over the patient - that's the task of the family to organize, a call to the receiving facility to verify this is helpful.
   
4. Making sure the transport costs are covered by insurance (here this will make a doctor's recipe needed) or by the family (signed cost agreement, we have some forms on the car).
   
5. Getting information about the patient. Making very clear that the releasing hospital has the duty to give all needed information - they have at least here, even if the patient refuses their treatment they need to inform further care about the things happened. this by vocal instructions and by a (preliminary) letter.
   
6. If patient needs care above the scope of my equipment, make sure I get it. A patient recovering from heart surgery is someone I want to have an ECG on and a defi ready plus an i.v. line running. On our BLS ambulances we have those possibilities, if not: get one who has.
   
7. Transport. Just as any other patient.
   

I know that some hospital staff may take an AMA personally and refuse to beeing friendly any more. Been there, experienced that, as well as with random patients and with family members. Such behaviour may proof that it was the better decision to leave this hospital. From an ambulance view, the process is not that uncommon and not complicated.

In the given scenario there are at least five things that make me wonder:

1. The ambulance had to do an hour drive around just to take over the patient from the same spot they were in the beginning. Why didn't they notify dispatch themself or stand by when family calls dispatch? May have things shortened a bit.
   
2. The hospital does a lame job on passing the patient properly. I don't see any reason they can't give a proper report to a further caring medical crew. They have to document it anyway, the patient has a right to have this info and the ambulance crew needs it. So I see almost a violation of any medical care practise in NOT giving the needed info.
   
3. Does the receiving facility know of the patient? What if they have no bed available, some important caring device defective or simply refuse to take the patient (because it's a known non-payer or else)? The ambulance crew would have a real bad time with this patient on board then...I for sure would have checked this before taking over the patient.
   
4. Was it clear who pays for the transport? Here, insurances do pay only when a written receipt of a doctor is present (in emergencies the receiving hospital has to give one, but that is not the case here). If we are unsure if such a receipt is present, we are obliged to have the patient sign a cost agreement. Can't see this issue covered in the original post.
   
5. If the crew thinks it should be an ALS transport, then why does dispatch think otherwise or why does the crew leader accepts this? If beeing uncomfortable then something is wrong, especially if higher level of care including more adequate equipment would be available: either I can handle it or I can't. Crossing fingers is not the only BLS option. Having sound arguments for getting ALS is. At least the argumentation "I need ALS because..." should be in the scope of BLS staff, not needing a supervisor...
   

[CPhT]

In the given scenario there are at least five things that make me wonder:

The ambulance had to do an hour drive around just to take over the patient from the same spot they were in the beginning. Why didn't they notify dispatch themself or stand by when family calls dispatch? May have things shortened a bit.

We weren't 100% sure that they (the family) would actually go through the process, and that our rig would be given the assignment. We thought it would go to an advanced rig, so they could do IV and monitors.

The hospital does a lame job on passing the patient properly. I don't see any reason they can't give a proper report to a further caring medical crew. They have to document it anyway, the patient has a right to have this info and the ambulance crew needs it. So I see almost a violation of any medical care practise in NOT giving the needed info.

My lead tech tried to explain that very thing to the attending doc at the originating facility. They would hear nothing of it though, and still sent us on our way with just a signed AMA form.

Does the receiving facility know of the patient? What if they have no bed available, some important caring device defective or simply refuse to take the patient (because it's a known non-payer or else)? The ambulance crew would have a real bad time with this patient on board then...I for sure would have checked this before taking over the patient.

That was the part where we, as the crew, dropped the ball. We did NOT notify the receiving facility of the incoming patient. We just "showed up". Luckily, the receiving hospital had plenty of beds. Also, it was a non-profit hospital (St. Something-or-other Mercy), so they would have taken the patient regardless of if they could pay or not. Actually, I think that's law here that ANY hospital has to take and care for a patient, regardless of if they can or can't pay for the care.

Was it clear who pays for the transport? Here, insurances do pay only when a written receipt of a doctor is present (in emergencies the receiving hospital has to give one, but that is not the case here). If we are unsure if such a receipt is present, we are obliged to have the patient sign a cost agreement. Can't see this issue covered in the original post.

That's a good question. I'm honestly not sure how we would go about that subject, or if it's even the crew's responsibility here. I'll have to check with them when I ride again on Sunday.

If the crew thinks it should be an ALS transport, then why does dispatch think otherwise or why does the crew leader accepts this? If beeing uncomfortable then something is wrong, especially if higher level of care including more adequate equipment would be available: either I can handle it or I can't. Crossing fingers is not the only BLS option. Having sound arguments for getting ALS is. At least the argumentation "I need ALS because..." should be in the scope of BLS staff, not needing a supervisor...

I found out later that the basis of the dispatches argument for having our BLS truck run the call was that the pt had stable vitals, within normal limits, and had no chief complaints except the bad service she was receiving at the originating hospital, and her HX of heart surgery. Dispatch made the case that her prior history alone didn't warrant an ALS truck, and that we were close enough to the receiving facility that even if things went wrong, we would be able to switch from priority 3 to priority 2/1 and still have a good chance. It made sense to me, and seeing how the patient wasn't as big of an issue as she could have been, I accepted the answer without any further questioning. Things may have been drastically different if she would have gone sour.

[ERDoc]

This story is pretty shitty on the original hospital's part. Even if the pt wanted to be transferred and was told to sign AMA, they should have made the appropriate arrangements to have the pt transferred. This poor family may be stuck with a large bill. I have transferred people who did not want to be at my hospital. I have no problems making the arrangements to get them where they want to go, despite the fact that it is a pain in the ass and very time consuming. I explain to them that we can provide whatever service they need and that by requesting to be transferred there is a good chance that they will get a bill for the ambulance ride as it is not medically necessary. By going to another ER, instead of making the pt a direct admit, there is going to be another ER charge and most insurances won't pay for two ER visits (although given the 5 week difference this may not be true).

When I was a dispatcher for a private transport company, in a situation like this, we were required to get a credit card approval or cash before transporting. If the insurance covered it then the family got their money back (so I am told).

As for the level of care needed, I don't see anything that requires ALS. The OP only said they took out the IV and did not say anything about drips. Maybe this was just a heplock.

[CPhT]

As for the level of care needed, I don't see anything that requires ALS. The OP only said they took out the IV and did not say anything about drips. Maybe this was just a heplock.

I wish I could have found out what the PT was on. The family didn't know, the nurses took the bags with them when the left the room, and the attending doc sure wasn't sharing any info.

[Just Plain Ruff]

I wish I could have found out what the PT was on. The family didn't know, the nurses took the bags with them when the left the room, and the attending doc sure wasn't sharing any info.

That makes me think there was at least one drip going and an IV. What that drip was, no-one is certain. Let's be glad this patient tolerated the transport well.

I think the crew and the hospital (originating) dodged a HUGE HUGE bullet here. No matter that they signed out AMA. Were they informed of the ramifications of their signing out AMA in the middle of the night? Were they informed that the ceasing of the medications could put them at risk? Were they told that the transport from here to there was risky in the best of times?

What did the AMA form show for risks and benefits of AMA'ing? I'd be curious to know what was written.