How do you handle a situation where Hospitals try to have you transport unstable patients..?

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aguyinems1993

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EMTLife Members,

This is my first post on here. I've browsed around on this forum for a while looking for advice and reading cool stories... I've finally figured I'd sign up! Seems like a really great community and a lot of help. I figured I'd ask y'all about how to conduct yourselves in a certain fairly common situation in IFT. Anyways, here's the breakdown...

I've been an EMT for about 4 months total, so I am still fairly new, and I remember my FTO telling me about how sometimes hospitals and nursing facilities will make attempts to dump unstable patient on you for transport, and to be careful with this. I've only been through it about 3 times, but every single time staff ends up getting angry or impatient and uncomfortable to be around afterwards. This one happened today, and particularly bugged me and was a total Murphy's Law situation.

We arrived to pickup a pt for a long ER to ER transport... about 30+ minutes. The pt was hypertensive, tachypneic, and somewhat hypoxic. BP was almost 200 systolic, respiratory rate was 30+, heart rate was adequate but SPO2 was 89. The RN administered medication to lower the BP to get them back down to baseline, so we waited for the pt to stabilize. In short, vitals remained unstable with BP around 160-170 for about 30-40 minutes. We reported all this to our dispatch, and even they felt somewhat uncomfortable with transport since it was going to be a long one... they thought we should wait as well. It was a long wait and finally the nurse told us the Dr. wanted to speak with us. I had a bad feeling. Thank Murphy and his amazing laws, but the pt went from 160-170 systolic to 120 systolic and perfectly adequate vitals 5 minutes before the Dr. entered the room. We transferred pt to our gurney quickly and got out of there. O2 was still a bit low so I put pt on 2lpm O2 via nasal cannula. I told the Doc that the vitals just returned to baseline right before he entered the room. I apologized for any inconvenience... he was cool about it, definitely a bit annoyed but just glad to see this transport finally go through.

Would any of you have handled this situation differently? It just absolutely sucked and our luck made us look bad IMO. Anyways, just thought I'd share this... Thanks for reading if anything. Have a good day!
 
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You are going to get a lot of very different responses here. For a lot of us a 30 minute transport is not even close to being considered long. In my area we routinely do ER to ER transports of several hours and there are other areas where the transport time is even longer.

A systolic BP of 200 does not automatically make the patient unstable. You would be surprised with how many people out there have undiagnosed hypertension.

Nursing facilities usually call for transport when the patient becomes unstable. If you do not feel you can properly treat and transport this patient you should call for some resources that are able to. Since I am a medic in the field, I do not have the option of calling in and handing this patient over to someone else (unless it’s a thunder chicken) so I have to transport this patient no matter how stable or unstable.

Hospitals should attempt to stabilize the patient to the best of their ability but their ability is going to depend on their resources on site. The hospital should also be able to identify what resources this patient needs during transport. If you arrive at the hospital and do not feel comfortable taking this patient then refuse and let the hospital know why.

So far I have only refused one transport from ER to ER on an ALS unit. It was for a 6 month old who the sending hospital was seriously considering RSI on. I went and told the doctors that an ALS unit in my system can not safely transport this patient because I don’t carry appropriate medications or a ventilator or even have the ability to intubate pediatric patients. They then decided to fly a pediatric speciality team out to do the transport.
 
DesertMedic66 said:
You are going to get a lot of very different responses here. For a lot of us a 30 minute transport is not even close to being considered long. In my area we routinely do ER to ER transports of several hours and there are other areas where the transport time is even longer.

A systolic BP of 200 does not automatically make the patient unstable. You would be surprised with how many people out there have undiagnosed hypertension.

Nursing facilities usually call for transport when the patient becomes unstable. If you do not feel you can properly treat and transport this patient you should call for some resources that are able to. Since I am a medic in the field, I do not have the option of calling in and handing this patient over to someone else (unless it’s a thunder chicken) so I have to transport this patient no matter how stable or unstable.

Hospitals should attempt to stabilize the patient to the best of their ability but their ability is going to depend on their resources on site. The hospital should also be able to identify what resources this patient needs during transport. If you arrive at the hospital and do not feel comfortable taking this patient then refuse and let the hospital know why.

So far I have only refused one transport from ER to ER on an ALS unit. It was for a 6 month old who the sending hospital was seriously considering RSI on. I went and told the doctors that an ALS unit in my system can not safely transport this patient because I don’t carry appropriate medications or a ventilator or even have the ability to intubate pediatric patients. They then decided to fly a pediatric speciality team out to do the transport.
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Thank you so much for the reply. I really appreciate it. I guess I knew that I was going to end up transporting... but I just wanted to wait for it to go down a bit before we got the pt on the gurney... it was a 30+ minute transport without traffic, but traffic and transport time was going to increase significantly if we would have waited another 15 minutes... the call was nothing too crazy... I'm just super annoyed that it was just my luck that the vitals would return to a perfect baseline as soon as the doctor would walk in! It's not even like I began to transport knowing they were a tad high, but confident that the pt would be okay... nope, Doc walked in and vitals became absolutely perfect...like a dream set of vitals lol. He probably thought I was being way too dramatic. Being new and looking back on that call, I feel like maybe I was being somewhat of a stickler; and it's just nice to hear how much more experienced EMTs and medics like yourself would have handled it. I just hope that doctor doesn't hate me too much at this point lol! Thank you! :)
 
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Aside from Desert's great post....the only thing I have to add is you shared numbers. Your concern was numbers in determining comfort level and "not stable for transport". As you gain more experience, more knowledge, etc...numbers are just that, numbers. My question is how did the patient look, how did they act, what were they saying...you know, the entire clinical picture.

Do not get tunnel vision and lose yourself in the numbers game...
 
I have a regular I pick up that lives in 200 systolic. Not that 200 is good, but it would catch my attention if he WASNT at least 170 when I see him. There are people who have adapted to being hypertensive and playing with the BP too much when you don't need to can also be problematic.

Like ak said, don't get caught up in numbers. There is a reason teachers preach treat the patient and not be the monitor.
 
For truly unstable patients, my answer is no.

Your patient doesn't sound so unstable as to preclude them from travelling 30 minutes by ambulance. You picked a foolish hill to die on.

Also, recognize that they aren't going to get any better where they are. Sometimes, we have to push the envelope a bit because a higher level of transport isn't available within a reasonable amount of time.
 
Disclaimer: I've only glanced over the other replies. So forgive repetitiveness.

Here is my initial concern, you said you're an EMT. I would not allow this transfer to go BLS, however if you're on an ALS unit that's another issue.

Onto the main point... As a general topic of transporting unstable patients, it's a case by case basis. Am I equipped to manage this patient? Why are they being transferred? Where are they being transferred from and to? How far? All questions I need to ask myself.

For this specific patient, 30 minutes is not all that far. Nearly all of my 911 transports are at least 30 minutes, and every hospital to hospital transfer is 45 minutes to 3 hours. This patient doesn't sound all that unstable to me. Sure, some of his vitals suggest an underlying problem, and we need to be vigilant and concerned, but I don't forsee this patient dying within the next few hours.

How do I handle it? Well, like I said, it depends. If the patient can truly benefit from the transport, then we do what we need to do to get the patient to definitive care, while also making sure we are as prepared as possible for the worst. Yes, there is a chance things can go south, but that's what we are trained to do.

Now, if there is no reasonable benefit to transfer, or the patient is unlikely to survive the transport, we can talk about options. I'll usually go above the RN to the doctor and have a grown-up conversation between two medical professionals. Not to suggest that nurses aren't grown up medical professionals, but in my experience the ones who cause these type of "push them out the door" problems are egotistic and acting from emotion, not from logic.
 
I wouldn't really feel comfortable taking him BLS either, but I have taken patients exactly like that (and worse) BLS on 911 jobs (All ALS unavailable is our dispatch centers favorite phrase)

I do agree with the others in asking, is the patient really unstable though.

What was he being transferred for?
What was his mental status?
Any stroke signs?
Was he symptomatic from the HTN?
What was his diastolic number?
What was his usual BP?
Was the SpO2 getting a good capture?
 
Your numbers dont tell me anything.

His systolic was high, and? Does he have complaints relating to such?
His respiration were high and pulse ox low, why? Is he a COPD patient who lives at 89%? Does bumping up his NC to 6lpm or 10lpm change anything? Is he always on oxygen? What do his lungs sound like? What other hx does he have?

Why is he even in the ER in the first place and why do they want him transferred? On the surface, i would probably feel comfortable taking this patient if those were his numbers and he didnt have any other issues. 30 Minutes isnt that bad
 
aguyinems1993 said:
In short, vitals remained unstable with BP around 160-170 for about 30-40 minutes.
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The first time that I took myself to the ED for a mental health problem, my BP was 169/99 upon arrival. Normal for me is around 110/70. I was stable enough to drive myself to the hospital (although I shouldn't have).

I'm wondering why your patient's BP dropped so precipitously. Over what period of time did the systolic go down to 120?
 
Seirende said:
I'm wondering why your patient's BP dropped so precipitously. Over what period of time did the systolic go down to 120?
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I think he said that a nurse gave the patient a medication for his blood pressure
 
vc85 said:
I think he said that a nurse gave the patient a medication for his blood pressure
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Ah yes, that would probably be it.
 
What's the big deal? he's hypertensive (enough to raise my eyebrow, but not enough for me to panic), with a RR of 30 (not too bad, assuming everything else was normal). but do you think he's going to die anytime soon? if you put him on a NC, does his SPO2 increase?

Good call with speaking to your dispatcher.... you are right to keep them appraised on the situation, but if you were seriously considering refusing the trip, i would have asked to speak to a supervisor or someone in management.

Pissing off a nurse or having them impatient with me isn't at the top of my list of concerns, especially if my actions are justified and are being done with the approval of my management. Especially if they are trying to bully me into transporting an unstable patient who needs a higher level of care than I can provide.

We get called to transport trainwrecks from nursing facilities all the time (as well as super stable patients). They can't handle the patient, so they call 911. transports from the ER are a little different, because they have a doctor who can try to stabilize the patient, but if they can't, they will send them out too.

For this patient, my question would be, is there anything that I should reasonable expect to happen to this patient in the next hour that I can't correct, that a higher level pre hospital provider can. Based on what you describe, assuming not other abnormalities other than some elevated vitals, I'd be comfortable taking this patient, especially if I was given a good report from the RN as to why the BP and RR were elevated.
 
Sometimes, a patient will not be "stable", yet transport is needed.
 
By definition pt would need to be unstable in some way for there to be a need for hospital to hospital transfer: otherwise the 1st hospital would either keep the pt or release them.
I have been considered unstable before due to BP at 82/40; and had an ED doc order Dopamine to be hung on me. I refused it from the nurse and asked to speak to the doctor: he came in and I politely told him to ask his patient what his normal BP is before ordering medications. I walk around about that.
I also walk around about 90% SPO2.

I have transported very unstable patients before because if I didn't the hospital would likely kill them (or they would die because the hospital they were in couldn't save them). And for what ever reason they couldn't be flown at the time.

My normal transport time now is 45-90 minutes for my FT job and 105-125 miles for my PT job. and most of our patients are ALS and so are unstable in some way. Fly less than you think we would. You get used to it, and transport them.

As you get more experience you will learn to watch the patient, not the monitor; worry how your patient looks and acts don't worry about what the numbers say.
 
johnrsemt said:
By definition pt would need to be unstable in some way for there to be a need for hospital to hospital transfer: otherwise the 1st hospital would either keep the pt or release them.
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Not quite. The patient may be completely stable but hospital A doesn’t have the services that the patient needs.

Also insurance is a huge thing. We have a hospital that does not accept Kaiser insurance so they will frequently transport out completely stable patients to a hospital that accepts their insurance.
 
johnrsemt said:
By definition pt would need to be unstable in some way for there to be a need for hospital to hospital transfer: otherwise the 1st hospital would either keep the pt or release them.
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Question for you: How does an acute care hospital with no cardiology resources treat or release a STEMI patient? They will have to transfer them to a stemi-center. Stable or not, they will have to transfer them.

Also, like DesertMedic66 said, insurance reasons. Kaiser hospitals with transfer out and VA hospitals will transfer out if you are not a veteran and you walk in. Stable or not.
 
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"Unstable" is a relative term. In my opinion unstable means they have a reasonable chance of deteriorating to a state that requires some type of ALS intervention in the near future. If that potential intervention is outside your scope of practice or capabilities then refusing to transfer is probably reasonable, especially if other options are available. Be prudent but not overly cautious.
 
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