# Don't have a heart attack in a hospital parking lot



## ffemt8978 (Dec 5, 2009)

http://www.google.com/hostednews/canadianpress/article/ALeqM5i_hq8SeLicxALX1eBk4qPnY1qRRQ


----------



## colafdp (Dec 5, 2009)

This same sort of incident happened this summer at a Saskatoon hospital too. 

http://www.ctv.ca/servlet/ArticleNe...tal_review_090422/20090422?hub=Health&s_name=


----------



## JPINFV (Dec 5, 2009)

> "are more prepared for safely removing people from vehicles."



Oh please. It's not exactly like removing someone from a wrecked car.


----------



## Burlyskink (Dec 5, 2009)

Thats crazy, when I cut my knee they came and brought me a wheel chair... I wasn't even in a life threatening condition. That said I don't understand why they didn't go out, it did say they didn't know how to extricate but the guy had a heart attack, there was no trauma involved.


----------



## spinnakr (Dec 5, 2009)

What it all comes down to:

They're all afraid of being sued.

Plain and simple.

Of course, I would personally be far more likely to sue if you LEFT me out there waiting for paramedics than if you risked some possible spinal injury by bringing me into the facility.  Especially - ESPECIALLY!! - if I were having a heart attack with no known trauma.


----------



## Burlyskink (Dec 5, 2009)

spinnakr said:


> What it all comes down to:
> 
> They're all afraid of being sued.
> 
> Plain and simple.


Yea but, technically wouldn't they be sued for doing nothing? I mean don't they have a duty to act? it was in their parking lot.


----------



## JPINFV (Dec 5, 2009)

^
I'm not sure if Canada as a law similar to EMTALA.


----------



## spinnakr (Dec 5, 2009)

Burlyskink said:


> Yea but, technically wouldn't they be sued for doing nothing? I mean don't they have a duty to act? it was in their parking lot.



Like I said, *I* would be more likely to sue over that than the liability for spinal compromise.  But, they're trying to get out of it by calling 911...  instead of the "common sense" course of action (helping the guy).

I think the policies, as they were (quite ineffectively) explained at the link, more or less deal with it:  someone should go at least assess the man, but if necessary, call 9-1-1.

"If necessary" is the key part, and I think from a culpability standpoint, no sane judge or jury would deem 9-1-1 necessary in this case.  

If I were the family of the man this happened to (or the man himself!), I would be suing.


----------



## Aidey (Dec 6, 2009)

You gotta love where lawyers have gotten us as a society. 

One of the hospitals I spent a lot of time at while in paramedic school had a similar policy. It wasn't a huge hospital, but the main building went out more than up, with several sub-clinics attached to it. Physically attached, as in you could get from point A to point B without going outside. 

Two of the attached facilities are a SNF and a catch all clinic that serves a specific minority group in the area. If either of these facilities needs to send someone to the ED they have to call an ambulance and have the pt transported via 911. The hospital staff can't wheel someone through the building, even if the patient is attended by an RN or MD. These transports can both be measured in hundreds of feet and go through parking lots, but the policy is to have the pt transported via ambulance. 

The ED staff will also not physically help anyone outside of 50 feet? (I think it's 50 feet, its some number of feet) away from the main ED doors. Even then, all they are supposed to do is wheel out a wheelchair. They can not help lift or provide any medical care until the patient is in the building. 

On one hand I can understand how asinine policies like these seem. On the other hand I understand that the insurance companies who insure hospitals and their staff are dealing with huge amounts of money and liability and I can see where they would want to try and reduce situations that put the hospital at risk for problems.


----------



## VentMedic (Dec 6, 2009)

There are many reasons for this and if you real the EMTALA regulations you will find the classifications for different facilities and what is considered part of the ED.   Regulations by several accrediting agencies also prevent an ED physician from leaving the ED and abandoning his/her patients.  Part of the terms of being an ED is that there must be a physician present for any emergencies that might enter that ED.  For this reason, the RNs and RRTs manage the codes in many hospitals until another qualified physician arrives. 

Sometimes it is actually to the patient's benefit if EMS is called to where they may be taken to the more appropriate facilty rather than wasting 6 hours waiting for an Inter-facility transfer and then finding the appropriate transport team who might be available to transport the patient.  

Some of the SNF and LTC facility contracts are also written to where the ambulances have included all calls for transport.  The other issue is at what rating the facility has for required emergency equipment and response.   In one major hospital in California, the SNF is actually located inside the hospital and just down the hall from an ICU.  However, due to the city EMS contract and the facility's licensing, EMS has to respond to that SNF and then take the patient to the ED.   They also do not have to take the patient to the ED of that hospital or can be diverted to another ED. 

Safety is another issue and availability of staff. When you have several hundred feet to move a patient and just one licensed professional (RN) and a transporter, if the person codes there will be even bigger questions to answer.  It is not like in the movies where you do CPR on a moving stretcher as someone is wheeling you and the patient through doors.  That is just as detrimental to the patient as a controlled move.  The effectiveness of the CPR would be very poor. As well, the RN may have to stabillize BP or rhythm and now they are in the middle of a hallway going nowhere.  We do wheel even critical patients all over the hospital campus but not to and from what is considered "outpatient" or a different type of facility and it is a planned or controlled move.  

It is also a concern for the employee to be without the protection of their hospital's liability insurance if they are off what is considered hospital grounds.  They may not be covered for any medical intervention or by workmen's comp if they attempt to move a patient without proper equipment and while out of what is considered the boundary.  Good Sam laws probably would not protect them either.  While some might think lawsuits are frivilous but if it is your house and income on the line, it can be an issue. 

This is not just hospitals that have these rules.  We have had and still have many situations on a daily basis in EMS where the nearest truck can not be dispatched to a scene that they are closest to because it is not their zone or contract.   We've even had ambulance station directly across the street from a scene but could not be dispatched because the patient was on the other side of the street in a different rescue district.  We also have "ALS" trucks coming to a LTC for another patient but who can not assist with an emergency happening at the same time in that facility.  Or, we have  "ALS" transfer trucks that must call for the FD or County ALS to initate advanced life support procedures.   The public (and other health care professionals) also gets confused with our BLS and ALS system.  They want to know why you aren't doing more for the patient or at least transporting them when the hospital is across the street but you as BLS might have to wait another 10 minutes for ALS at arrive to accompany you.


----------



## Outbac1 (Dec 6, 2009)

This has been all over the news here. That hospital (about 200miles from me), is a small hosp. with a very small ER. Everything gets shipped out to bigger facilities. While they should have been able to take the man in we don't know how busy they were in the ER. They probably didn't have staff to do it. I'll try to find out what their staffing is. They were lucky, the ambulance base is accross the street and the crew was actually there. That crew is routinely used for long hauls and coverage comes from farther away. Such is SSP.

 Hospitals calling for a paramedic crew to do immobilazitions for them is common. At my hosp. the nursing staff often get people from their cars that drive up sick or dying (literally). I have taken my share of people from their private cars on hospital grounds. Although I was there anyway after a call. I don't remember ever being called to go over and take someone in from their car.  It will be interesting to see what unfolds from this.


What is EMTALA?


----------



## ffemt8978 (Dec 6, 2009)

Outbac1 said:


> What is EMTALA?



http://www.emtala.com/


----------



## Jon (Dec 7, 2009)

When I worked hospital security for a little bit, this was a huge gray area. We were stationed practically at the ED's door, and as the ED staff knew me, and knew that I was an EMT (at the time, )., I was pressed into service occasionally to help with getting patients out of vehicles when they were unable to move on their own power.

There was limited, and somewhat conflicting policy on what to do when someone was out front of the ED in need of aid. Some staff and policies suggested that we shouldn't lift patients from vehicles, others suggested we should. Myself and many of the ED techs that worked as prehospital providers were willing to lend a hand when needed, although we preferred to have the patient move under their own power as much as possible.

Further, when medical emergencies occured on hospital property, but outside the facility, EMS was usually activated to transport the patient, as the hospital didn't really have adequate equipment to move a sick/injured person from a far parking lot or one of the outbuildings into the ED.


----------



## JPINFV (Dec 7, 2009)

Jon said:


> Further, when medical emergencies occured on hospital property, but outside the facility, EMS was usually activated to transport the patient, as the hospital didn't really have adequate equipment to move a sick/injured person from a far parking lot or one of the outbuildings into the ED.



Strange, because every hospital I've been in had a ton of these that were used 100% of the time for all patients in one department and (at least in the hospital I volunteered at) 80-90% of the time to move patients inside the hospital provided the bed didn't have a motor assist built in (motor assist hospital bed > hospital gurney > regular hospital bed).


----------



## daedalus (Dec 7, 2009)

Funny story: LAC-USC (LA County General) has a bag titled something like "curbside delivery kit"near the ED door, and it is filled with OB stuff. Something must have happened in the past. 

As to the thread, I must echo VentMedic's statements. EMS may be called for a variety of reasons to hospital grounds, and a lot of the time there is attitude displayed towards staff. Unprofessional. I am humbled that other medical professional see a need for me and my skill set, and when I am called to physician offices and hospital grounds, and am happy to provide my services. And like Vent has also said, we in EMS also have our fair share of ridiculous rules and no where is that more true than southern california.


----------



## EMSLaw (Dec 7, 2009)

The irony of the situation, though, is that this was Canada, which is at least reputedly less litigious and has less of a medical malpractice insurance crisis than places in the US.  

Intellectually, I understand why the hospital did what it did.  Emotionally, this one is hard to swallow.  The idea of a nurse or other medical professional who is willing to leave someone in the parking lot mere feet from the ER door to suffer or die seems repugnant.  I understand why they did, but if that man had died, and the family had sued, it'd be hard to sell the hospital's policy to a jury.

On to the whole "I would sue..." thing - remember, you have to actually be damaged to sue and win.  He didn't die, so there would have to be proof that he would have had a better outcome had he made it into the ED five minutes sooner.  And that's aside from the other elements of the case.  So, yeah, anyone can sue anyone for anything, but that's totally different from actually having a case.


----------



## VentMedic (Dec 7, 2009)

EMSLaw said:


> Intellectually, I understand why the hospital did what it did. Emotionally, this one is hard to swallow. The idea of a nurse or other medical professional who is willing to leave someone in the parking lot mere feet from the ER door to suffer or die seems repugnant. I understand why they did, but if that man had died, and the family had sued, it'd be hard to sell the hospital's policy to a jury.


 
Yes but how many times is it stressed for scene safety and to protect yourself? If you are risking injury by moving a patient you do not have the proper equipment or the proper staff then it might be best to wait 5 minutes for those that do. Also, do you jeopardize the other patients already under your care? We've had many discussions about stopping at MVCs with a patient already in the truck. What about the health care professionals who may have many patients under their care? If there are only 2 RNs in the ED and 12 patients, one RN would be limited in getting a patient safely on an ED stretcher which rarely can be lowered close to the ground. The ED doctor should not leave his/her ED except for extreme inhouse emergencies and even for that it is not advised. In some places hospital staff don't leave the hospital without a security escort. Extra security is sometimes brought in for shift changes. If a GSW patient is thrown out of a car in front of our ED, we do have LEOs secure the scene before any medical professional approaches. That is to disarm the patient and crowd control for those who might be friends (or enemies) of the patient. We do have a lot of practice with this and have learned from past mistakes that you do not just rush out to every patient in the parking lot. 

There are tough decisions to make and somethings won't be easy. 
We've had EMS providers who have watched people burn in their homes and cars. We've had people drown while EMS providers stoodby without access to rescue equipment. We've had people fall to their deaths while just out of reach. We've watched people die in riots where the scene was not safe to approach the patients. We've waited for the power/gas company or sometimes the FD to safely shut off power/gas before we get the patient. We've delayed transport on bariatric patients until adequate staff could arrive to safely move the patient. We've waited on scene for the right equipment to extricate the patient. If the "best" extrication and lifting or carrying equipment is not alway available, you will usually have at least 4 - 6 FFs to assist the two EMS providers. Also, look at the total number of EMS providers on scene as compared to 1 RN and 1 security guard at a hospital. At one sprained ankle we get no less than 6, mostly Paramedics, responding and that is their only patient they must be concerned for at the time.


----------



## EMSLaw (Dec 7, 2009)

I agree with you for the most part, Vent, and as I said, on a purely intellectual level, I understand their policy and why they did what they did.  We've all had calls where someone needed help and, for whatever reason, we couldn't provide it.  But on an emotional level, which is how most people who are not EMS providers are going to see this, it's just hard to understand how a hospital would call an ambulance for someone fifty feet from the door.

What if he had walked into the door and collapsed?  The same lifting and moving requirements apply, so it can't simply be that EMTs are experts at moving people.  I guess the insurance would no longer be a concern, and the fact that we have to worry about that at all is a sad reality of the times we live in.  

Also, consider the location.  A big inner-city hospital in a bad neighborhood has different security concerns than a small rural hospital in bucolic suburbia.


----------



## VentMedic (Dec 7, 2009)

EMSLaw said:


> What if he had walked into the door and collapsed? The same lifting and moving requirements apply, so it can't simply be that EMTs are experts at moving people. I guess the insurance would no longer be a concern, and the fact that we have to worry about that at all is a sad reality of the times we live in.


 
Once he entered the door there could be more professionals that can help to lift, since this is common, and not have to worry about totally leaving their other patients without supervision for very long. Many hospitals also have lift teams or transporters that can then respond as they are able to do curbside removal of patients from POVs. Unlike EMS, hospitals don't always have scoops or back boards but rather Hoyer lifts and slides, neither of which is practical in a parking lot.

Some small town hospitals get themselves into the most trouble because they are so friendly. They let their guard down.


----------



## DrParasite (Dec 7, 2009)

VentMedic said:


> Unlike EMS, hospitals don't always have scoops or back boards but rather Hoyer lifts and slides, neither of which is practical in a parking lot.


really, so if the patient enters the ER with a potentially cervical spinal injury, the  ER doesn't put them on the backboard with C-collar?  I know of two ERs in my area that have at least 1 backboard that is owned by the ER itself.

As much as it sucks, falls in the parking lot typically get an EMS response, and maybe a hospital security one.  I can recall several times we were called for falls, only to have security cancel us as they already assisted the patient into the ER.

most hospitals can't/won't treat anyone outside their doors due to liability reasons.  most doctors and nurses won't go outside that door to treat anyone, but I know many who will get enough help to at least put the patient into a wheelchair and bring them inside.  and the triage nurse, once done with patients, can typically leave her post to assist someone in a car, as she isn't treating a patient in the typical sense of the word.  if he or she actually gets off the chair to help


----------



## VentMedic (Dec 7, 2009)

DrParasite said:


> really, so if the patient enters the ER with a potentially cervical spinal injury, the ER doesn't put them on the backboard with C-collar? I know of two ERs in my area that have at least 1 backboard that is owned by the ER itself.


 
Some do have backboards or could use one left behind by EMS. However, it is generally not the practice. And again, you may only have one RN and one security guard to carry a patient instead of 6 FFs. There is another reason EDs keep a backboard available and that is for IFT by ground or flight. Sometimes a patient is brought in by EMS without packaging or even walks in with a spinal fracture. It may be easier to stabilize, move and transfer the patient to another facility on the backboard.  In other words the patient is packaged with the backboard in the ED for a flight or ambulance transport.  

In the hospital, patient will be positioned to where their movement is limited, placed on a bed that is designed for accessories attached such as tongs, halos, traction, pad stabilizeres or whatever and they may be taken to the OR for stabilization of the OR. Neuro will also customize or get a specific sized collar to fit the patient's needs. We have slides and specially designed Hoyers and other lifts that also can move patients with different injuries. But, some equipment runs on tracks in the ceilings of the OR, ICU and ortho units since not all beds accomondate the legs of the Hoyer. If a fall occurs inside the hospital, any of this equipment can be utilized and not a back board.


> *As much as it sucks,* falls in the parking lot typically get an EMS response, and maybe a hospital security one. I can recall several times we were called for falls, *only to have security cancel us* as they already assisted the patient into the ER.


 
You complain when you are called and you complain if not needed?


----------



## RyanMidd (Dec 7, 2009)

My girlfriend (RN) and I understand the inherent differences in our jobs and the policies that come with them, but the one scenario we can always depend on for a heated discussion is as follows:

Man with DNR is in a hospital, several floors up. Paramedics are leaving hospital, and do not know this patient or his physician. DNR man jumps out window, lands on sidewalk in front of medics. He is in respiratory arrest, followed by cardiac arrest, but he is alive. Medics are about to begin treatment, nurse runs outside and says, "Stop, this man has a DNR. Don't do anything".

Knowing the Health Act where I live, as well as similar 'Good Samaritan' type acts, I am all for working the guy. Unless I have online or present medical direction in the form of a valid DNR signed by a local MD, I will work it.

RN girlfriend, however, is adamant that they should take the nurse's advice and leave it be, especially since he is still technically at the hospital and under their care.

We both have a few more salient points than this, but this thread reminded me of the one scenario that will guarantee a fight between her & I. =)


----------



## EMSLaw (Dec 7, 2009)

Please tell me that isn't a real scenario?  

Based on the answers above, the patient is now outside the hospital - he's eloped! (I just love that word in the context. ).  I guess you work the code until presented with a valid pre-hospital DNR.


----------



## VentMedic (Dec 7, 2009)

EMSLaw said:


> Please tell me that isn't a real scenario?


 
That has actually happened a few times at a couple of hospitals in my area. In those situations the physcians at the hospital made contact with EMS by radio if physical contact was not possible and assumed responsiblity of the patient. However, one patient survived the fall without coding and had to be transported from scene to a trauma center. In that situation, the patient remained in control of EMS. Another hospital which was not a trauma had a shooting outside of its ED door with the victim being a patient in the ED who stepped outside for a smoke. EMS, already at the hospital, assumed control of the patient and transported the patient to the trauma center just a few blocks away.


----------



## EMSLaw (Dec 7, 2009)

VentMedic said:


> That has actually happened a few times at a couple of hospitals in my area. In those situations the physcians at the hospital made contact with EMS by radio if physical contact was not possible and assumed responsiblity of the patient. However, one patient survived the fall without coding and had to be transported from scene to a trauma center. In that situation, the patient remained in control of EMS. Another hospital which was not a trauma had a shooting outside of its ED door with the victim being a patient in the ED who stepped outside for a smoke. EMS, already at the hospital, assumed control of the patient and transported the patient to the trauma center just a few blocks away.



If it were a physician coming out and saying to terminate the code, as long as he was willing to take responsiblity for the patient, I'd do what he said.  But, depending on local protocols, of course, a nurse generally isn't qualified to give that instruction.


----------



## DrParasite (Dec 9, 2009)

VentMedic said:


> You complain when you are called and you complain if not needed?


I complain when I am called, we respond and get on scene, and when not finding a patient, are told by dispatch that security brought the patient to the Emergency room 5 minutes ago.  If security is going to call us, at least let us get to the patient.  or take her directly to the ER and don't bother calling us, since that is what they will end up doing.


----------

