Ever refuse a transport?

[mycrofft]

Scenario: pt found unconscious lying in pool of blood originating from mouth. Hx multiple liver disease, elevated hepatic enzymes, and hypertension. Emergently sent to closest ER, and admitted.
After sucking a portion of their blood bank dry in their ICU, the pt is sent by private ambulance to a second (contracting) hospital. Throughout the thirty minute trip the pt was receiving IV fluids (not blood), still bleeding orally/vomiting requiring suctioning to maintain airway and aerosal precautions. Receiving hospital was underjoyed.
Any thoughts? Could you refuse such obvious "turfing"?
NOTE: Pt survived the trip and is now depleting hospital #2's blood reserves.

 

[PrincessAnika]

my understanding is that if pt is coming off a floor aka already admitted, pt must be transferred to a room/floor @ rec' facility bc ER is not admission it is ?pt abandonment? to transfer from an ICU to an ER. in order to transport from ICU to ICU, rec' facility must have approved and have a room ready/waiting for pt.

eta - why is pt bleeding orally? what is being done to fix the problem?

 

[VentMedic]

Correct. For a patient to be transferred from one ICU to another, there must be an accepting physician who has rec'd a full report from the sending physician and a bed ready for the patient. There will also be an RN to RN report.

Since this patient was taken emergently to the closest hospital initially, hopefully the second hospital will be on of higher care. Of course, there are insurance issues as some want patients insured by them in their own facilities as soon as possible provided they are stable enough to transport.

For IFT, the only time I have refused to transport has been for a very unstable patient or a dead one. We prefer not to transport someone who is coding every 5 minutes. If the patient is maxed on all pressors and still has a low BP, we will notify the other facility and our medical director to determine if we can abort the transport.

I would also ensure there is a patent airway and that includes intubating before departing the sending facility. That would also given better control of aerosolized infectious spray. If the ICU physician is not in agreement with that, he/she can speak with whatever MD I am working for. In this case the patient may have esophageal varices from portal HTN which may make passing an NGT difficult or place the patient more at risk. (Oh no...not a Blakemore tube!)

There have been times when the ALS Paramedic does not feel comfortable with an ICU patient and can refuse the transport. Likewise, the ICU can refuse to release the patient to a crew they feel is not qualified for that transport. In that situation, members of the ICU staff might be asked to accompany or preferably there will be a CCT team with qualified personnel.

http://www.google.com/imgres?imgurl...mage_result&resnum=6&ct=image&ved=0CCMQ9QEwBQ

 

[DrParasite]

In this case, I would say no.

1) when doing an interfacility run between hospitals, the sending doc will typically speak to the receiving doc. in theory, the sending facility knows the patients condition, and still accepted him.

2) you are just a paramedic. people above your pay grade (MD and RNs and LWS) set this up. as long as the patient doesn't deteriorate (everyone knows he isn't in good shape to begin with), you still should take the patient where the transport was set up for. also hopefully you will be going with a CCT team which should have an RN whose scope may be slightly broader.

3) unless you think the patient may die enroute, I don't think you can refuse a transport, at least not without a supervisor's approval or approval from your medical director.

 

[firetender]

Long time ago in a Land far away!

I once stood up to (successively) two ER physicians, a neurologist, an orthopod, and the Chief of staff of the hospital for a full night refusing to transport a 25 yo soldier with a fresh spinal cord injury and fx femur whose BP was fluctuating wildly whom they wanted to buff and turf to the nearest Veteran's Administration Hospital, 90 miles away!

I had picked the kid up and out of a canal after he was hit and run off the road by a car, he on a motorcycle. I stabilized him as best I could and when we came in to the hospital, they just notified the VA and told me to take him there. I simply refused to relinquish control of my patient until I felt comfortable transporting him.

In the process, I got a second opinion from the head of the ER of a neighboring hospital who then talked the company dispatcher into letting me stay on standby at the hospital. I really had no idea of the potential consequences at the time, but I held my ground as diplomatically as I could until the Chief of Staff sided with me.

That was the first and only time I asked another doctor for a second opinion, and it made a difference, so if you ever get in such a pickle, you can always say "It's been done before!"

Once the kid had been stable for about two hours, I did transport. He did okay on the way up. I released him to a literal nightmare of a hospital where I had to leave him -- literally HAD TO leave him because there was no where else to take him and starting a ruckus at a VA Hospital is a Federal Offense, and they let me know that! -- on one of their gurneys on a LINE behind five other Emergency patients in almost as bad a shape as he.

Let's just call the impression that night left on me "Indelible!" It was a call I wished I had and I'm glad I didn't find out what happened next.

 

[Aidey]

One of the most nerve wracking transports I've ever done was VA to VA. The pt had a laundry list of problems, but his acute issue was pericardial effusion post CABG. The guy had an ejection fraction of like 14%. He was also in acute renal failure and totally fluid overloaded. I'm pretty sure the only reason his heart was even still pumping is because the increased fluid volume was counteracting the pressure from the effusion.

I very nearly refused to do that transfer, even the pts nurse said he wouldn't blame me for not taking the patient. I ended up having a talk with the doc, and found out the pt had a DNR and he/his family thoroughly understood the transfer risks. Since my biggest concern had been what the heck I was going to do if he crashed, the DNR made it a mostly moot point.

 

[VentMedic]

I once stood up to (successively) two ER physicians, a neurologist, an orthopod, and the Chief of staff of the hospital for a full night refusing to transport a 25 yo soldier with a fresh spinal cord injury and fx femur whose BP was fluctuating wildly whom they wanted to buff and turf to the nearest Veteran's Administration Hospital, 90 miles away!

I had picked the kid up and out of a canal after he was hit and run off the road by a car, he on a motorcycle. I stabilized him as best I could and when we came in to the hospital, they just notified the VA and told me to take him there. I simply refused to relinquish control of my patient until I felt comfortable transporting him.

Refusing to transport a patient that you do not feel qualified and/or comfortable assuming care for is very different than refusing because you don't like the other hospital or the patient's insurance.

While many VA hospitals do have a bad reputation, some are also serious SCI and TBI centers. Many other hospitals do not always have the capability to handle such injuries with a neurosurgeon on call and an ICU that can do the specialized care before and after the surgery.

You may also dislike the facility that has the cath lab but that is the best place for your STEMI patient to go to. You may hate some inner city trauma centers because of experiences you have had in the rest of hospital or the general ED. But, if your patient has suffered a serious trauma, that is where they should go.

We have had ambulance crews agrue about doing simple transports to another hospital because of insurance, special procedures and family/patient preference. If the argument is not about assuming care that you are not comfortable with but rather that you don't want to do the transport "just because" you don't want to then there is a serious issue with you understanding the responsibilities of your job and the contract the ambulance service has with the hospital.

Sometimes hospitals do over estimate the abilities of a Paramedic. It is okay to say "whoa!" at the beginning so the hospital can find a higher level of transport care. It is generally those Paramedics that accept these patients "just because they can" and not because they should that run into serious problems and deliver a dead patient to the other hospital. One should know their limitations and be honest about them.

 

[mycrofft]

Vent's all over it.

Pt blew esoph varix or varices (newbies, liver sx's plus HTN plus oral bleeding or even tarry stools equals the equivalent of a hand gfrenade in the chest).

Initial fire EMS diverted from contractual hospital to a closer hospital at their discretion due to pt condition. After a few days the closer and superior hospital declared the pt stable, a private ambulance carried the pt to the contractual hospital. Second hand reports from laypersons indicate the pt still had blood hung, continued to bleed to some degree all the way (NG drainage?), and the receiving hospital was "really unhappy".

Some facilities, especially nursing facilities, will turf out a "sinker" to an ambulance trip with the hopes that the pt expires in the ambulance ior at the dr's office and not in their facility/on their statistics. This time it probably was a combination of not wanting to take my type of clients, and the pt was sucking thier blood bank.

 

[Veneficus]

Pt blew esoph varix or varices (newbies, liver sx's plus HTN plus oral bleeding or even tarry stools equals the equivalent of a hand gfrenade in the chest).

Initial fire EMS diverted from contractual hospital to a closer hospital at their discretion due to pt condition. After a few days the closer and superior hospital declared the pt stable, a private ambulance carried the pt to the contractual hospital. Second hand reports from laypersons indicate the pt still had blood hung, continued to bleed to some degree all the way (NG drainage?), and the receiving hospital was "really unhappy".

Some facilities, especially nursing facilities, will turf out a "sinker" to an ambulance trip with the hopes that the pt expires in the ambulance ior at the dr's office and not in their facility/on their statistics. This time it probably was a combination of not wanting to take my type of clients, and the pt was sucking thier blood bank.

Do I understand this correctly?

The original hospital kept this guy for days with an esoph bleed and just kept pouring blood into him?

Did they even try to fix it surgically and couldn't or were they hoping it would magically stop bleeding on its own?

I could see why the receiving facility was a little unhappy especially if the pt was turffed to a lower level of care.

 

[Aidey]

While many VA hospitals do have a bad reputation, some are also serious SCI and TBI centers. Many other hospitals do not always have the capability to handle such injuries with a neurosurgeon on call and an ICU that can do the specialized care before and after the surgery.

What I've observed about the 3-4 VA hospitals I've been to is that they often have very well developed inpatient programs, and under-developed ERs. At one of the hospitals the ER was legally certified as an urgent care center even, not an ER. We could transport there, but there was a very specific protocol for it, and we had to call ahead and get permission from the doctor (although at night there was only a PA, if they needed a doc they called one from upstairs).

At the VA hospital where I live now we have to call ahead and clear the transport with the charge RN if there is any question about if the VA can handle the pt. If they don't think they can handle the pt, they tell us what hospital to go to (they have higher care contracts) and then they call that hospital and get it all cleared so the pts VA coverage will pay.

 

[VentMedic]

There are also other situations when the higher level hospital takes a patient requiring their level of care but also wants the sending hospital to take the patient back once the acute situation is resolved and can be handled by the lower level. This is done quite often with critically ill infants. Once they are on their way to recovery after a stay in a Level 3 NICU, we will do a back transport to the sending nursery for the rest of the recovery. This prevents overcrowding at the major centers where beds are needed for more seriously ill/injured patients. However, doing a back transport can be difficult as the sending hospital may not want these patients back who might still have a long and expensive recovery. As well, they may also have find placement for long term care and there is often a wait list at some of the LTC facilities or rehab centers. Some EMT(P)s don't know how valuable a transport out of a hospital to one of these centers is if it means getting a bed freed up for a critically ill patient to be transferred in. It may sound like a big shuffle and dump game but there usually is a master plan in mind.