# EMTALA / JCAHO violation?



## HawkMedic (Jun 6, 2012)

I had a call the other day for a person with a syncopal episode, however presenting with some ACS symptoms. 12 lead performed with Junctional Rythmn/ RBBB (and what the hospital is calling an Inferior Infarct). Patient is unstable so we transported to the local facility only to have our heads nearly ripped off by the charge nurse, even after explaining the nature of the call. Patients subsquent 12 leads do not show any signs of an AMI/ STEMI, and patient refuses chest pains/ pressure throughout the call. Basically poor diagnosis on the part of the hospital (my opinion), then they treated the patient and tried to get EMS to perform an interfacility w/ heparin, and tridol bolused. EMS advised they would need a nurse to transport with the patient. They refused so EMS refused. Who is right, and is there any violation that has occurred. (Outcome of patient: No STEMI/ AMI; Troponin, CPK and CK are all normal; Patient refused catherization at cath lab) Patient is now suffering from issues associated with heparin administration. Patient was on coumadin at the time.


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## usalsfyre (Jun 6, 2012)

So you took the patient to an inappropriate facility, didn't have the education or equipment to deal with the subsequent transfer it created and then tried to get the hospital to bail you out by sending a nurse who's probably unfamiliar with the transport environment along for the ride, and are pissed off because they refused? Did I get all that?

"Unstable" patients don't get "stable" in the ED, especially of an inappropriate facility. Medics need to grow a pair and go to the right place.


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## Christopher (Jun 6, 2012)

HawkMedic said:


> Patient is unstable so we transported to the local facility...



Let's consider a best case scenario assuming he was having a fat-daddy MI; we'll assume your local hospital is right down the road and the big medical center is 45 minutes away:


Minimal scene time = 5 minutes
Distance to Bandaid Station (Local Hospital) = 5 minutes
Unloading + Handoff = 5 minutes
Physician Evaluation and Orders = 5 minutes
Stat Labs = 10 minutes
Additional stabilization interventions = 20 minutes
Organization of Critical Care Transfer = 0 minutes (you guys were there)
Loading of patient = 5 minutes
Driving to Level 1 Trauma/Neuro/Pediatric/Astronaut Care Center = 45 minutes
Unloading + Handoff = 5 minutes
Physician Evaluation and Orders = 5 minutes
Trip to cath lab = 5 minutes
Procedure Start to Balloon Inflation = 10 minutes

I count 125 minutes from arrival on scene to definitive care, potentially 50 minutes arrival to fibrinolytics.

If you instead went directly to the Big Mamma Jamma Center the patient would receive definitive care in approximately 90 minutes. Even better would be transmission of the 12-Lead while enroute to get the Physician's overread, if you're not interpreting the 12-Lead, which could activate the STEMI system shaving perhaps 10-20 minutes at the receiving facility.

For just about every urban and suburban system, favor bypassing to the appropriate facility over pit stopping at a bandaid station.

Moreover, it sounds like your dude had a Stokes-Adams attack, worsening intraventricular conduction defects, or is experiencing Sick-Sinus-Syndrome and potentially needs a stat pacemaker. You've got a transcutaneous pacer available anyways.

Either way, I'm with usalsfyre...we're Paramedics and can handle an "unstable" cardiac patient as well as any community hospital...usually better!


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## Aidey (Jun 6, 2012)

HawkMedic said:


> I had a call the other day for a person with a syncopal episode, however presenting with some ACS symptoms. 12 lead performed with Junctional Rythmn/ RBBB (and what the hospital is calling an Inferior Infarct). Patient is unstable so we transported to the local facility only to have our heads nearly ripped off by the charge nurse, even after explaining the nature of the call.



How was the pt unstable?


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## silver (Jun 6, 2012)

HawkMedic said:


> I had a call the other day for a person with a syncopal episode, however presenting with some ACS symptoms. 12 lead performed with Junctional Rythmn/ RBBB (and what the hospital is calling an Inferior Infarct). Patient is unstable so we transported to the local facility only to have our heads nearly ripped off by the charge nurse, even after explaining the nature of the call. Patients subsquent 12 leads do not show any signs of an AMI/ STEMI, and patient refuses chest pains/ pressure throughout the call. Basically poor diagnosis on the part of the hospital (my opinion), then they treated the patient and tried to get EMS to perform an interfacility w/ heparin, and tridol bolused. EMS advised they would need a nurse to transport with the patient. They refused so EMS refused. Who is right, and is there any violation that has occurred. (Outcome of patient: No STEMI/ AMI; Troponin, CPK and CK are all normal; Patient refused catherization at cath lab) Patient is now suffering from issues associated with heparin administration. Patient was on coumadin at the time.



Why was a nurse needed in your opinion?


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## Veneficus (Jun 6, 2012)

usalsfyre said:


> So you took the patient to an inappropriate facility, didn't have the education or equipment to deal with the subsequent transfer it created and then tried to get the hospital to bail you out by sending a nurse who's probably unfamiliar with the transport environment along for the ride, and are pissed off because they refused? Did I get all that?
> 
> "Unstable" patients don't get "stable" in the ED, especially of an inappropriate facility. Medics need to grow a pair and go to the right place.



Well said.


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## Veneficus (Jun 6, 2012)

Christopher said:


> Let's consider a best case scenario assuming he was having a fat-daddy MI; we'll assume your local hospital is right down the road and the big medical center is 45 minutes away:
> 
> 
> Minimal scene time = 5 minutes
> ...



You forgot to add time to call a physician at the receiving facility and arrange appropriate transfer of care. Otherwise instead of a direct admit to interventional cardio, radio, or whoever is running the cath lab, that pt will be re-evaluated in the receiving ED adding further time.

I also think you are overly generous in your evaluation estimates. Probably add at least another 10 minutes to them, plus time for radiology and labs.


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## Christopher (Jun 6, 2012)

Veneficus said:


> You forgot to add time to call a physician at the receiving facility and arrange appropriate transfer of care. Otherwise instead of a direct admit to interventional cardio, radio, or whoever is running the cath lab, that pt will be re-evaluated in the receiving ED adding further time.
> 
> I also think you are overly generous in your evaluation estimates. Probably add at least another 10 minutes to them, plus time for radiology and labs.



I should have bolded "best case"  The radiologist was in the ED for free doughnuts and the lab technician got a gift card that AM from the ED Nurses.


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## exodus (Jun 6, 2012)

I don't understand is why you are jumping Hawk's butt. He interpreted the 12 lead to not be an MI so he did transport to a fully capable hospital that just had dumbasses for staff. The dumbass comment is reinforced by the fact he was refused cath.


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## Aidey (Jun 6, 2012)

The issue is that he claimed the patient was an unstable cardiac patient, and that is why they transported to the closer, less capable hospital. Then when the hospital attempted to transfer the patient to the more capable hospital EMS threw a fit and demanded a RN accompany them due to medications that are normally well within the paramedic scope.


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## Handsome Robb (Jun 6, 2012)

Aidey said:


> EMS threw a fit and demanded a RN accompany them due to medications that are normally well within the paramedic scope.



For what it's worth we'd have to call for a CC-P with a pump to take this transfer. Only our CC-Ps can take Heparin drips, partially because they are the ones with pumps. 911 trucks don't have 'em and the hospitals here would burn to the ground before they let us take one of theirs.


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## DesertMedic66 (Jun 6, 2012)

Aidey said:


> The issue is that he claimed the patient was an unstable cardiac patient, and that is why they transported to the closer, less capable hospital. Then when the hospital attempted to transfer the patient to the more capable hospital EMS threw a fit and demanded a RN accompany them due to medications that are normally well within the paramedic scope.



For my area ALS could not do that transport. We would need either the hospitals nurse to ride with us and continue patient care or we would have to call in one of our nurses and get the CCT rig ready (at least 60 minutes).


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## Veneficus (Jun 6, 2012)

firefite said:


> For my area ALS could not do that transport. We would need either the hospitals nurse to ride with us and continue patient care or we would have to call in one of our nurses and get the CCT rig ready (at least 60 minutes).



So the long and short if it is what USALS said, don't go to a facility that cannot handle the patient.


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## Aidey (Jun 6, 2012)

The OP said the meds were bolused. There may not have been a drip running.

Edit: I also concur with the idea that you shouldn't take a patient to a facility that can't handle them, and don't be surprised when they get pissed off when you do.


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## silver (Jun 6, 2012)

Aidey said:


> The OP said the meds were bolused. There may not have been a drip running.



Thats what I thought as well. In my experience in the cath lab we usually received transfers and ED patients that were loaded with ASA, clopidogrel, and heparin bolus. We sometimes got drips. For any interventions the physicians would bolus and then run a drip with bivalirudin most of the time, because it could get your PTT up in literally minutes (or time it took to prepare for an intervention).


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## usalsfyre (Jun 6, 2012)

exodus said:


> I don't understand is why you are jumping Hawk's butt. He interpreted the 12 lead to not be an MI so he did transport to a fully capable hospital that just had dumbasses for staff. The dumbass comment is reinforced by the fact he was refused cath.


What was a facility without interventional cardio capability (good for more than just STEMIs BTW) going to do with an unstable cardiac patient? Classic EMS "don't die in my truck" dump and run.

No violation of EMTALA, but a jackass move on EMS's part.


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## HawkMedic (Jun 6, 2012)

I'm glad to her the opposition; I'm just doing the job I am required to do! The patients condition being hemodynamically unstable is what caused the transport unit to goto the local facility which is protocol. The patient did not require a cardiac intervention center. I'm an NREMT-I not a paramedic, and my question is solely if the ER is refusing to except the patient and wishes for EMS to transport than is this an EMTALA, or JHACO violation?


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## HawkMedic (Jun 6, 2012)

Silver to reply to you; I cannot transport Heparin, or Tridol; It's outside my scope of practice!


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## Christopher (Jun 6, 2012)

HawkMedic said:


> I'm glad to her the opposition; I'm just doing the job I am required to do! The patients condition being hemodynamically unstable is what caused the transport unit to goto the local facility which is protocol. The patient did not require a cardiac intervention center.



Protocols are guidelines. Would a post-arrest patient with a BP of 70/40 be "hemodynamically unstable" and have to go to the local facility? Or would they go to the appropriate facility...food for thought.



HawkMedic said:


> I'm an NREMT-I not a paramedic, and my question is solely if the ER is refusing to except the patient and wishes for EMS to transport than is this an EMTALA, or JHACO violation?



The ED cannot refuse to accept a patient brought in by EMS unless they are on Full Diversion...which even then that would be a giant gray area. EMS would likely win on that one.

You can, however, refuse to accept a patient for transfer if you believe the patient is outside your scope of care or if the patient requires interventions/medications you cannot legally perform/administer.


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## Veneficus (Jun 6, 2012)

Christopher said:


> Protocols are guidelines. Would a post-arrest patient with a BP of 70/40 be "hemodynamically unstable" and have to go to the local facility? Or would they go to the appropriate facility...food for thought..




I would ask if EMS would take a patient requiring a trauma surgeon to a center that didn't even have a surgeon if he was unstable?

In my home state, the dept of public safety actually had to codify trauma transport criteria. 

EMS will never be a profession if they can't even figure out to take trauma patients to a trauma center and cardiac patients to a cardiac center.

If I started asking people on the street if they would take a trauma patient to a trauma center or a hospital that doesn't have trauma, (substitute cardio, neuro, etc as you like) I bet most of them would guess the right answer.

Why do we have to even tell EMS people this?


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## HawkMedic (Jun 6, 2012)

Usalsfyre I appreciate your opinion, but I don't think you read it right!


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## usalsfyre (Jun 6, 2012)

HawkMedic said:


> Usalsfyre I appreciate your opinion, but I don't think you read it right!



What did I misread? Explain to me the decision to take the patient to a hospital that may not have been able to take care of them? How was the patient "unstable"? 

Closest facility dumps are weak sauce to me. It says "I don't want to take responsibility for this patient".


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## Christopher (Jun 6, 2012)

Veneficus said:


> Why do we have to even tell EMS people this?



Isn't that our motto though?



> _You call, we haul!_



I think these are symptoms of treating our profession as a vocation rather than a clinical field.


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## HawkMedic (Jun 6, 2012)

It's not my decision to make; I have protocols to follow that were assigned by doctors. The Cath lab in the area is new and cannot perform all the proceedures that some of the other individuals were talking about. It's basically exploritory; We usually fly out individuals to other major hospitals. I did what was expected of me and can sleep well at night, but my question was more about the hospital if they need to have the patient transferrred to there facility, given an appropriate assessment, and transported by an appropriately staff crew if this in any way violates EMTALA, or JHACO. Again, I appreciate what your getting at but not sure your reading it right!


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## Aidey (Jun 6, 2012)

You're not explaining it very well. You still have not explained why the patient was hemodynamically unstable. You have not explained whether the pt had active IV drips running, or he had only received a bolus of the medications. You have not explained why the hospital the pt was transported to was better than the one with the cath lab, even if the cath lab is limited in what procedures were performed.


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## socalmedic (Jun 6, 2012)

*back to the OP*

to answer your original question if they had contacted the destination hospital and had the patient accepted, AND you are capable of providing the ordered interventions en route (ie, Nitro/heparin IV), AND the necessary paperwork was prepared to be transported with the patient (Physician Order for transport, Upgrade in care, Ect) then no they have not broken EMTALA.

we take unstable transfers regularly from our local bandade center to the trauma, Stemi, Stroke center. we also bypass for the "most appropriate facility". being that your not a paramedic, i feel that you most likely made the right decision to request a RN if you cannot provide ACLS care. I take nurses from time to time if there is a med that is out of my protocol, they are usually very excited to get to ride in the ambulance...h34r:


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## truetiger (Jun 6, 2012)

HawkMedic said:


> It's not my decision to make; I have protocols to follow that were assigned by doctors. The Cath lab in the area is new and cannot perform all the proceedures that some of the other individuals were talking about. It's basically exploritory; We usually fly out individuals to other major hospitals. I did what was expected of me and can sleep well at night, but my question was more about the hospital if they need to have the patient transferrred to there facility, given an appropriate assessment, and transported by an appropriately staff crew if this in any way violates EMTALA, or JHACO. Again, I appreciate what your getting at but not sure your reading it right!



Why not just fly him to the appropriate hospital?


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## HawkMedic (Jun 6, 2012)

Truetiger the hospital usually accepts the patients and transports them by air if they meet the criteria, apparently the patient didn't meet the criteria.


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## HawkMedic (Jun 6, 2012)

Thanks socialmedic. I'm unfamiliar with EMTALA, and couldn't find alot of resources about it. That answered my question just fine!


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## truetiger (Jun 6, 2012)

Out of curiosity, what were his vitals? Any EKG?


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## Medic Tim (Jun 6, 2012)

HawkMedic said:


> I understand the point of view saying that the patient needs to be transported to the most appropriate level of care! I shouldn't need to explain what hemodynamics are. There weren't any IV's started other than a 16g L/AC w/ R/L flowing KVO (EMS started). The other medications were bolused. The hospitals are the same with the exception of the exploritory cath lab. I believed the patient wasn't a STEMI so I went to the local facility + the instability factor. I don't need a lesson in choosing the right facility. My question is simple. Patient had a syncopal episode, followed by dyspnea and dizziness. So I transported local for the doctors to sort it out.



any reason you are avoiding questions? you do not have any vitals posted and then state the pt is unstable. you will get better answers to your questions when you supply the info needed or requested.


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## Aidey (Jun 6, 2012)

HawkMedic said:


> Thanks socialmedic. I'm unfamiliar with EMTALA, and couldn't find alot of resources about it. That answered my question just fine!



You're kidding right? A google search of EMTALA comes up with tons of information. 

I also would like to know why you are avoiding questions.


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## HawkMedic (Jun 6, 2012)

varying junctional to Accerated junctional w/ RBBB; Initially onscene the ECG showed ST segment changes in Inferior; 15 lead performed without any Right sided involvement; Third ECG and subsequent ECG's show no signs of STEMI. Our protocol states we are unable to call a STEMI with QRS duration greater than 0.12ms. Initial vitals are 40-60 HR; 70/40 BP; 90%SAO2; 28 RR; ETCO2 32.


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## Aidey (Jun 6, 2012)

Are there paramedics in your system?


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## VFlutter (Jun 6, 2012)

Medic Tim said:


> I shouldn't need to explain what hemodynamics are.



I do not think anyone here is trying to get you to explain what hemodyamics are, I think they want a more detailed description of the patient's condition. Your definition of unstable may be very different then mine. 

And just because they were not having a STEMI does not mean they should not be transferred to a Cath lab facility. You said they were in a junctional rhythm, an EP study may be warranted to rule out any dysrhythmia as the cause for the syncopal episode. 

Also could you not have called OLMC to ask about the possibility of diverting to the more appropriate facility if your protocols required you to go to the first?


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## Christopher (Jun 6, 2012)

HawkMedic said:


> varying junctional to Accerated junctional w/ RBBB; Initially onscene the ECG showed ST segment changes in Inferior; 15 lead performed without any Right sided involvement; Third ECG and subsequent ECG's show no signs of STEMI. Our protocol states we are unable to call a STEMI with QRS duration greater than 0.12ms. Initial vitals are 40-60 HR; 70/40 BP; 90%SAO2; 28 RR; ETCO2 32.



Right Bundle Branch Block does not obscure the ST-segment in a manner which prohibits traditional STEMI criteria from working.


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## HawkMedic (Jun 6, 2012)

I'm avoiding some of the questions cause I don't need someone monday night quarter-backing a call when they don't understand the area/ resources that are available. And I though someone on hear would have more knowledge than I did about EMTALA, and JHACO. I'm not getting the information I need from a web search thats why I tried blogging.


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## VFlutter (Jun 6, 2012)

Medic Tim said:


> any reason you are avoiding questions? you do not have any vitals posted and then state the pt is unstable. you will get better answers to your questions when you supply the info needed or requested.





HawkMedic said:


> varying junctional to Accerated junctional w/ RBBB; Initially onscene the ECG showed ST segment changes in Inferior; 15 lead performed without any Right sided involvement; Third ECG and subsequent ECG's show no signs of STEMI. Our protocol states we are unable to call a STEMI with QRS duration greater than 0.12ms. Initial vitals are 40-60 HR; 70/40 BP; 90%SAO2; 28 RR; ETCO2 32.




Did their condition improve before the hospital requested the transfer? I am assuming it did because I do not think they would bolus tridil with that pressure. ETC02, where they intubated or is that off the nasal cannula?

We are not trying to "quarter back" your call, however a very clear description of the patient's condition and situation are required before talking about if there was a violation


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## HawkMedic (Jun 6, 2012)

ChaseZ33 said:


> Did their condition improve before the hospital requested the transfer? I am assuming it did because I do not think they would bolus tridil with that pressure. ETC02, where they intubated or is that off the nasal cannula?
> 
> There condition did improve with oxygen;  ETCO2 was done by capnoline. The tridil, heparin, and asa caused dizziness and nausea to progress.


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## Aidey (Jun 6, 2012)

HawkMedic said:


> I'm avoiding some of the questions cause I don't need someone monday night quarter-backing a call when they don't understand the area/ resources that are available. And I though someone on hear would have more knowledge than I did about EMTALA, and JHACO. I'm not getting the information I need from a web search thats why I tried blogging.



How to you expect to get a real answer when you refuse to give us any information on the system or patient. Both of those play into how EMTALA applies. Stable/unstable is a huge part of whether a transfer is appropriate under EMTALA. I also can not understand why you can't find what you need on a web search. There is tons of information on EMTALA out there, including scenarios and court cases that give examples of how EMTALA applies. 



*On a site note THIS IS NOT BLOGGING! Blog is short for 'web log'. This is not a blog, this is a forum. /petpeeve *


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## HawkMedic (Jun 6, 2012)

I appolagize the the blog comment. And I didn't understand how exactly EMTALA worked so thanks for the information.


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## HawkMedic (Jun 6, 2012)

I'm just trying to prepare for a confrontation with the system director, so this doesn't happen again. If I'm at fault than so be it. I've heard alot of good comments, and I appreciate all the comments some are a bit over the top but it's still information to take home at the end of the day. Again I didn't find what I was looking for with the web search but I guess I'll try it again.


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## usalsfyre (Jun 6, 2012)

Hawkm


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## JakeEMTP (Jun 6, 2012)

For EMTALA: appropriate assessment by qualified (usually Physcian) person, stabilization, transfer arrangements with the most appropriate facility who will accept the patient and transfer by the most appropriate team.  

An ALS team can refuse a patient for transfer if it is outside of their scope. 

For JCAHO, a hospital must have a transfer policy in place. For your argument, you should respectfully request a copy from the ER Manager before your meeting.  Hospital staff do not like to be left hangin' themselves out on a limb either on a transport depending on some of your equipment and meds either. They may no have provisions to go on your ambulance like a separate narc box.  Their pharmacy gets a little upset if just a handful of meds are pulled for a transport.  If they need more meds and you don't carry it, the patient is screwed anyway.  Most hospitals don't lend their equipment out either since they don't know your abilities.  You may think something looks easy enough but you hang yourself, the patient and the hospital when you :censored::censored::censored::censored: it up on the road in the middle of nowhere.


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## lightsandsirens5 (Jun 6, 2012)

Be nice people....and remember, there is a "No legal advice" rule here on the forum.


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## lightsandsirens5 (Jun 6, 2012)

OP, are you a medic or a basic? What about your partner?

Did you guys get a 12 lead, or just a 3? I am asking because if you are a basic you probably have an excuse for transporting to the closest ER since sans 12 lead you don't know what is going on. No, that being said, you should be going off clinical presentation regardless of what the 12 lead shows and if the patient was truly "hemodynamically unstable" he should have been pounded via fastest transfer method to a facility equipped with an operational cath lab, be that in your ambulance or with HEMS. 

Additionally, I would say, be advised that if you ask a question on this site, expect people to ask for information. Especially when you give very little. There are lots of people on here that are critical thinkers, as they should be, that  like to make informed decisions and formulate informed opinions. Give the info needed to let others formulate the answer you are seeking. If you don't want to give out information, don't ask questions that require it.


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## 18G (Jun 7, 2012)

OP... do you not provide pre-notification or speak to a medical command physician at the receiving hospital regarding patient's you are deeming to be unstable while you're enroute?

Why didn't you consult and inquire about facility destination? Just curious. 

As far as EMTALA... the sending hospital must ensure that appropriate staff and equipment are present for patient transfer. If a nurse was needed and no other capable providers were available, legally they must send the nurse.


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## HawkMedic (Jun 8, 2012)

To answer some of the questions: I am an NREMT-I99; We have paramedics/ CRT-I's in the county. All of the county is volunteer with the exception of the supplemental paid staffing; So we rely on the volunteers to upgrade as driver most of the time. Occasionally we have a chase vehicle from the paid service upgrades. On this call I only had a first responder with limited expiriance (so basically just a driver). The patient presented with cardiogenic shock symptoms, along with (JVD, mild hypoxia, dyspnea, dizziness, urinary incontinence and syncope). I'm with Usalsfyre on the appropriate transport facility, however in the short period of time its difficult to know that in the 15 minutes with the patient is the symptoms going to improve or deteriorate. Luckly it wasn't an AMI, and the patients condition did improve. I did consult with the facility, and we transmitted the ECG to the other facility for diagnosis which they thought it was a STEMI. I hope that answers most of the questions! I'll try to remember not to be so vague in the future.


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## Veneficus (Jun 8, 2012)

was calling for an ALS intercept an option?


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## HawkMedic (Jun 8, 2012)

I'm not sure what your asking? I am an ALS provider just for clarification; If I was to transport to the other facility It's difficult to say when I would rendevous with another provider, and its not guarenteed that It would be a Paramedic.


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## HawkMedic (Jun 8, 2012)

I guess the other question I would ask is in the idea of transporting to the appropriate facility would you work an arrest by yourself? The variables are endless, and this case just proves the point that its called "practicing medicine". You'll probably never master it, even though I'm sure there are para-gods out there. And opinions are like :censored::censored::censored::censored::censored::censored::censored:s everyones has one. Its good to have some collected critism to balance things out though, and I do respect the views that everyone is bringing to this forum.


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## Veneficus (Jun 8, 2012)

HawkMedic said:


> I guess the other question I would ask is in the idea of transporting to the appropriate facility would you work an arrest by yourself? The variables are endless, and this case just proves the point that its called "practicing medicine". You'll probably never master it, even though I'm sure there are para-gods out there. And opinions are like :censored::censored::censored::censored::censored::censored::censored:s everyones has one. Its good to have some collected critism to balance things out though, and I do respect the views that everyone is bringing to this forum.



Usually, ALS is synonomous with a paramedic, but we won't quibble. 

But I am going to offer you a constructive professional observation. 

You do not seem to be comfortable with what makes a patient stable or unstable. 

It looks like you were overly concerned with "what if" than what you had. As time went on, you became more uncomfortable to the point of refusing a transfer that you caused by not going to the appropriate facility. 

The initial hospital looks like they were trying to bail you out by treating the patient as much as possible so you would have no issues on your trip.

It has been my observation and I admit I was the same way, that before I started seeing large amounts of truly unstable patients, that providers just don't have a good idea on what exactly unstable is. 

Your question about "would you work this code alone?" It wouldn't be the first time. But consider, you are going to need help. So your driver is going to have to pull over and do CPR. Because CPR and defib is what you need until help arrives.

If you drop a patient off at a hospital that cannot provide the needed treatment and the patient dies the outcome is no different than if he dies in your truck on the way to some place that can help.

Just like with trauma, it actually causes more delays and worse outcomes when you don't go to the trauma facility.

In fairness there are times when the closest facility is the right answer, but to put some perspective to that, in my whole career, in multiple states and countries, only 1 time have I ever encountered such a case. 

I will also qualify that it was basically the perfect storm of things that could go wrong. From inclimate weather prohibiting airmed, to a VFD that left the patient in the car uposide down in a ditch filling up with water because they were afraid of causing a secondary c-spine injury, an inexperienced partner, equipment failures, etc.

I would suggest you ask to spend spend some time in the regional ICU in order to become more comfortable identifying and managing critical patients.


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## TomB (Jun 8, 2012)

HawkMedic said:


> Thanks socialmedic. I'm unfamiliar with EMTALA, and couldn't find alot of resources about it. That answered my question just fine!



You couldn't find a lot of resources about it? The search term "EMTALA" yields over 55,000 results. Front page hits include Wikipedia, CMS, ACEP, etc. So astonish me. Where did you look?


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## Veneficus (Jun 8, 2012)

TomB said:


> You couldn't find a lot of resources about it? The search term "EMTALA" yields over 55,000 results. Front page hits include Wikipedia, CMS, ACEP, etc. So astonish me. Where did you look?



I don't know if the OP even looked, but i would just like to point out that in almost all of the EMTALA websites I have visited, there is usually some sort of disclaimer that says many of the tennants are open for legal interpretation and advice or information given is meant to serve as a guide rather than definitive rule.

I would stipulate that an EMS provider, who is also taught curriculum in terms of black and white, right and wrong, may not be proficent enough to extrapolate the needed information.

I have even had arguments with physicians on this very website who have been taught certain interpretations by people they respect, trust, and maybe admire were black and white and had to be challenged that multiple interpretations on the topics was debatable and often a matter of  local procedure rather than fact.


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## zmedic (Jun 8, 2012)

EMTALA basically says if someone shows up at your ER you must:

1: Do a medical screening exam.

2: Treat life threatening conditions and stabilize the patient

3: Transfer in appropriate fashion. (Ie patient unlikely to deteriorate enroute, patient consented to transfer, patient has been accepted by MD at receiving facility etc) 

If you show up with a patient that my hospital can't handle, it's an EMTALA violation for me to say "I'm not treating this patient, take them somewhere else." It isn't a violation for me to say "I'll treat this patient, but you should not have brought the patient here because we aren't a trauma center/don't have OB/GYN/are not a pediatric hospital/ whatever." 

Also if your ambulance service is going to bring patients to a hospital that isn't full service, there needs to be a system in place for how transfers are going to happen. It shouldn't be a surprise to the ER if you can't transfer a patient on a vent, on pressors etc.


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## rezmedic (Jun 10, 2012)

*Emtala*

I get into a lot of discussions about EMTALA and your original situation, which to me are two separate discussions.  EMTALA is about dumping patients without continuity of care, by the way I interpreted the explanation.  It means you can't drop a patient off somewhere without the receiving facility assuming care.  It seems to be grossly misunderstood, or I'm off base.  Perhaps someone can better explain it than that.  I've had MD's try to tell me according to EMTALA we can't have patient's from the same car and same car accident in the same ambulance.  ?
The second part of the original comment is that when we have unstable patients, or think we do, do we take them to the closest facility, or to the most appropriate one.  I will freely admit I'm often questioned about my decisions on this.  I have many times watched the service I volunteer with wait 40+ minutes for a helo rather than get into the ambulance and drive 35 minutes to the better choice.  Our other option is the medical clinic 10 miles away with a nursing home attached and an "ER" and I use that term loosely.  They don't have a doctor nights and weekends, and most of them refuse to come in until the RN on duty has evaluated the patient.  In a real emergency I never take patients there unless the patient absolutely refuses to go anywhere else.  They just end up buying 2 ER visits instead of 1.  It always seems to me that the people who don't want to go the 35-40 minutes to better care are less concerned with their patient than with their own lack of confidence in their skill set.  Too many EMT's forget that ALS starts with BLS.  I probably oversimplify but I will always try to get the patient to the right facility the first time.


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## Veneficus (Jun 10, 2012)

zmedic said:


> EMTALA basically says if someone shows up at your ER you must:
> 
> 1: Do a medical screening exam.
> 
> ...



If I am  not mistaken, there is a compassionate care clause to #3 which would negate the patient unlikely to deteriorate enroute clause?


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## jwk (Jun 10, 2012)

zmedic said:


> EMTALA basically says if someone shows up at your ER you must:
> 
> 1: Do a medical screening exam.
> 
> ...



Best, most non-judgmental post in the whole thread.

The only thing I would say to the OP is that with this crowd, try and get all the facts out there in your initial post.  It was like pulling teeth to get everything needed to form an opinion.


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## jwk (Jun 10, 2012)

Aidey said:


> How *to* you expect to get a real answer when you refuse to give us any information on the system or patient*.* Both of those play into how EMTALA applies. Stable/unstable is a huge part of whether a transfer is appropriate under EMTALA. I also *can not* understand why you can't find what you need on a web search. There is tons of information on EMTALA out there, including scenarios and court cases that give examples of how EMTALA applies.
> 
> 
> 
> *On a site note THIS IS NOT BLOGGING! Blog is short for 'web log'. This is not a blog, this is a forum. /petpeeve *



Spelling and punctuation - pet peeve.


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## zmedic (Jun 10, 2012)

Veneficus; said:
			
		

> If I am  not mistaken, there is a compassionate care clause to #3 which would negate the patient unlikely to deteriorate enroute clause?



There is a lot of grey areas that I don't pretend to be an expert on. Like what happens if you have a patient with a brain bleed who needs neurosurgery, but you don't have that ability at your ER. But the patient is actively herniating and you think they are going to deteriorate enroute. Can you transfer them? You are sending them to definitive care? 

Not sure. 

I think it's worth remembering that many people think they know about HIPPA, or EMTALA, and they are talking out of their butt. But educating them in the heat of battle usually doesn't work.


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## Aidey (Jun 10, 2012)

The reading I did indicated that if the benefits outweighed the risks then transfer was allowable. Basically the patient has to have been treated/stabilized to the maximum ability of the sending facility.


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## jwk (Jun 10, 2012)

Aidey said:


> The reading I did indicated that if the benefits outweighed the risks then transfer was allowable. Basically the patient has to have been treated/stabilized to the maximum ability of the sending facility.



Correct me if I'm wrong - but the decision to transfer from one facility to another is not a decision made by the medic, but between the transferring and receiving facilities/physicians.  They decide, you transport.  If you refuse to transport, for whatever reason that might be (good or bad), I assume there are other services that will.


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## RocketMedic (Jun 10, 2012)

In my system, establishing physical doctor-patient contact at an ER is even constituted as asking for on-line medical control, which means that they have to go to my base hospital. Obviously, there's a problem with this, since my base hospital has no specialty capabilities.

Ideally, a paramedic could initiate transport, even to out-of-area facilities, entirely based on what's needed for the patient, to include BLS downgrades and alternate transport arrangements.


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## Aidey (Jun 10, 2012)

jwk said:


> Correct me if I'm wrong - but the decision to transfer  from one facility to another is not a decision made by the medic, but  between the transferring and receiving facilities/physicians.  They  decide, you transport.  If you refuse to transport, for whatever reason  that might be (good or bad), I assume there are other services that  will.



Oh dear, I'm sorry. I didn't realize that as a medic who has no say in the decision making process I couldn't respond to a MD asking a question. Pardon me for attempting to provide clarification. I'll just go stand in the corner and wait for the paperwork to be filled out.


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## Aidey (Jun 10, 2012)

For the record: 



> 2. If an emergency medical condition exists, treatment must be provided  until the emergency medical condition is resolved or stabilized.*If the  hospital does not have the capability to treat the emergency medical  condition, an "appropriate" transfer of the patient to another hospital  must be done in accordance with the EMTALA provisions.*
> 
> 3. Hospitals with specialized capabilities are *obligated to accept  transfers from hospitals who lack the capability to treat unstable  emergency medial conditions*.



and 



> *7.  What is an appropriate transfer?*
> An "appropriate transfer" (a transfer before stabilization which is  legal under EMTALA) is one in which all of the following occur:
> 
> 
> ...



Sources

http://www.acep.org/content.aspx?id=25936 and http://www.emtala.com/faq.htm


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## Handsome Robb (Jun 23, 2012)

jwk said:


> Correct me if I'm wrong - but the decision to transfer from one facility to another is not a decision made by the medic, but between the transferring and receiving facilities/physicians.  They decide, you transport.  If you refuse to transport, for whatever reason that might be (good or bad), I assume there are other services that will.



You are correct but they also cannot "dump" an "unstable" patient on an EMS crew. I guess I shouldn't say the cannot do it, they certainly could but any medic worth their salt will refuse the transport. The sending physician is responsible for that patient until that patient reaches the receiving facility correct? Why would the sending physician not do everything they could to get that patient in a state fit for the transport environment before sending them out? I'm not willing to take someone who will likely code en route because of inadequate "stabilization" at the sending facility.

If that physician has set up a transfer to a facility that bypasses other capable facilities where does that fall? Example: an active STEMI being transfered from a facility incapable of providing PCI to another facility which will result in bypassing another facility capable of providing that patient definitive care. If it's within reason I'm perfectly OK with it but if they are asking me to drive a long distance past the facility being bypassed would it be wrong for the medic to chime in? I know being out of insurance coverage comes into play but in a situation like this what's more important, ease for the insurance company or patient care?

I know stable is controversial term at best, Dr. Jeffrey Guy has a good quote: "A stable is a place for horses, patients are compensated or decompensated". Why wouldn't the sending facility do everything in their power to keep that patient in a compensated state. I know patient care is dynamic and constantly changing but that just seems silly to me to "dump" a decompensated patient on a transport crew.


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## Veneficus (Jun 23, 2012)

NVRob said:


> You are correct but they also cannot "dump" an "unstable" patient on an EMS crew. I guess I shouldn't say the cannot do it, they certainly could but any medic worth their salt will refuse the transport.



I do not agree with that.

If a facility has no possibility of helping or even stabizing a patient, a transport on compassionate grounds is absolutely in order.

Not to you in particular, but I want to point out people die in ambulances. It is not a place where death is officially put on hold until at a hospital.

Taking an unstable patient from one hospital to another might be the best chance that patient has.

I think there are times it is appropriate for the medic to deny sitting the transfer. But that is a different thread.



NVRob said:


> The sending physician is responsible for that patient until that patient reaches the receiving facility correct? Why would the sending physician not do everything they could to get that patient in a state fit for the transport environment before sending them out? I'm not willing to take someone who will likely code en route because of inadequate "stabilization" at the sending facility.



So your plan is to let them die without help as opposed to try and get them somewhere that can help, simply because they might die on the trip?

Does that sound logical or reasonable to you?



NVRob said:


> If that physician has set up a transfer to a facility that bypasses other capable facilities where does that fall? Example: an active STEMI being transfered from a facility incapable of providing PCI to another facility which will result in bypassing another facility capable of providing that patient definitive care. If it's within reason I'm perfectly OK with it but if they are asking me to drive a long distance past the facility being bypassed would it be wrong for the medic to chime in? I know being out of insurance coverage comes into play but in a situation like this what's more important, ease for the insurance company or patient care?



Finanacial considerations are absolutely part of good patient care. 

From not ordering unwarrented tests to making sure the pt isn't forced into bankruptcy from the needed treatment when possible.



NVRob said:


> I know stable is controversial term at best, Dr. Jeffrey Guy has a good quote: "A stable is a place for horses, patients are compensated or decompensated". Why wouldn't the sending facility do everything in their power to keep that patient in a compensated state. I know patient care is dynamic and constantly changing but that just seems silly to me to "dump" a decompensated patient on a transport crew.



Because emergency rooms ad even the full capabilities of some hospitals cannot restore homeostasis with what they have. 

Many people think stabilizing a few numbers or lab values actually saves patients. 

That is just wrong. 

I can stabilize normal vitals on a corpse. That doesn't mean it will live again.


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## Handsome Robb (Jun 23, 2012)

I'll withdraw my statement seeing as Vene just shot it to pieces.


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## FLdoc2011 (Jun 23, 2012)

NVRob said:


> You are correct but they also cannot "dump" an "unstable" patient on an EMS crew. I guess I shouldn't say the cannot do it, they certainly could but any medic worth their salt will refuse the transport. The sending physician is responsible for that patient until that patient reaches the receiving facility correct? Why would the sending physician not do everything they could to get that patient in a state fit for the transport environment before sending them out? I'm not willing to take someone who will likely code en route because of inadequate "stabilization" at the sending facility.



From above:

2. If an emergency medical condition exists, treatment must be provided until the emergency medical condition is resolved or stabilized.If the hospital does not have the capability to treat the emergency medical condition, an "appropriate" transfer of the patient to another hospital must be done in accordance with the EMTALA provisions.

3. Hospitals with specialized capabilities are obligated to accept transfers from hospitals who lack the capability to treat unstable emergency medial conditions.




> If that physician has set up a transfer to a facility that bypasses other capable facilities where does that fall? Example: an active STEMI being transfered from a facility incapable of providing PCI to another facility which will result in bypassing another facility capable of providing that patient definitive care. If it's within reason I'm perfectly OK with it but if they are asking me to drive a long distance past the facility being bypassed would it be wrong for the medic to chime in? I know being out of insurance coverage comes into play but in a situation like this what's more important, ease for the insurance company or patient care?



You can certainly chime in as you group may have specific transport protocols or regs that need to be addressed but probably not going to make a difference in most instances, by that time the receiving place has accepted the patient and report has been given.  A lot goes into the process behind the scenes that you may not have been aware of..... maybe a closer facility refused to accept the pt or didnt have any available rooms or didn't have that specific specialty on call that night.... Any number of factors play in and by the time we get an accepting facility we may have already called a few different places.   

I think you're example is a little extreme, a STEMI with goal door to balloon times is not knowingly going to bypass a closer facility for one significantly further away for now good reason.   

We get a bunch of neuro transfers (bleeds) from hospitals in the region who are in our "network" since they have agreements in place to keep patient "in network" when I'm sure they are technically closer hospitals with similar capability.  I think in some of these instances one big advantage is they keep the money "in network" but these aren't necessary critically time sensitive issues.  We certainly wouldn't be getting a STEMI from a sister hospital an hour away.  

All that to say there are a number of factors in play that get sorted through before you have become involved. 
In this specific case the patient certainly doesn't seem unstable.   I don't consider being on a heparin drip unstable.


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## NYMedic828 (Jun 23, 2012)

HawkMedic said:


> varying junctional to Accerated junctional w/ RBBB; Initially onscene the ECG showed ST segment changes in Inferior; 15 lead performed without any Right sided involvement; Third ECG and subsequent ECG's show no signs of STEMI. Our protocol states we are unable to call a STEMI with QRS duration greater than 0.12ms. Initial vitals are *40-60 HR; 70/40 BP*; 90%SAO2; 28 RR; ETCO2 32.



Was pacing the patient an option?


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## jwk (Jun 23, 2012)

jwk said:


> Correct me if I'm wrong - but the decision to transfer from one facility to another is not a decision made by the medic, but between the transferring and receiving facilities/physicians.  They decide, you transport.  If you refuse to transport, for whatever reason that might be (good or bad), I assume there are other services that will.





Aidey said:


> Oh dear, I'm sorry. I didn't realize that as a medic who has no say in the decision making process I couldn't respond to a MD asking a question. Pardon me for attempting to provide clarification. I'll just go stand in the corner and wait for the paperwork to be filled out.



Lighten up there dude.  Am I wrong that the decision that a patients needs to be transferred from one hospital to another is one that is made by physicians at the two facilities?  Clearly nobody can force you personally to transport a patient, but again, if you don't, someone else will.  You aren't the one that decides the patient should be transferred - that's a simple fact.  I'm not arguing that you shouldn't know the reason, but simply that it's not you who decides if, where, and when.  

FLdoc has pointed out several things that do into the rationale of why a patient should be transferred to a given facility.  The reasons for transfer are up to someone other than you.  In-network, out-of-network, actual availabilty of needed services (maybe the only interventional cardiologist on duty already has more cardiac cath's lined up than he can handle), availability of an ICU bed, availability of an OR or anesthesia personnel at the receiving facility - whatever.  Maybe the family wants the patient at a specific facility - for example, if it were my family member getting transferred, I'd want them to go to MY hospital assuming the necessary services were available and the time issues weren't deleterious.


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## Aidey (Jun 24, 2012)

I did not say it was the medic's decision. I really have no idea where you got that from anything I have said. All I did was answer a question someone else asked and you started lecturing on how it wasn't the medic's decision.


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## ffemt8978 (Jun 24, 2012)

Do I really need to get involved in another thread this week?


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## STXmedic (Jun 24, 2012)

ffemt8978 said:


> Do I really need to get involved in another thread this week?



:nosoupfortroll:


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