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In regards to EMS intubation issues

Robert Smith rfsmithmd at comcast.net
Tue Apr 11 19:07:43 BST 2006


I was curious if you have a background in law. Actually I've always wondered
what a PA-C is. You always sound very knowledgeable on a variety of topics. 

It is probably just my ignorance but I'm unfamiliar with some of the
language and/or concepts in your post. I couldn't find them in the EMTALA
statute or regs. Maybe you could point me in the right direction.

I'm not familiar with "prescribing a course of care" and therefore I'm
unclear how I would see it to finality. ( I'd like to be able to prescribe
that all my patients get better )

I am familiar with the concept of the transferring physician still being
responsible for the patient until the patient arrives at the receiving
facility. This helps prevent dumping, the original intent of the statute.
I'm not familiar with the transferring physician being responsible until the
receiving physician physically encounters the patient or even what that
would mean. What if the receiving physician is not present when the patient
arrives? Went home; went to the OR etc. What if nurses or non-physicians are
the first to see the patient and initiate treatment? What if they
inappropriately triage the patient to a non-treatment area?

I'm not familiar with physicians and nurses being commonly successfully sued
for good Samaritan actions.

There is extensive language in EMTALA regarding responsibility for care
and/or transport of patients seen in outlying clinics or centers which are
part of a larger campus, with regard to the parent institution. I'm unsure
how this would relate to freestanding urgent care centers. Having called EMS
I don't know how much authority the on site physician would or should have
once the EMS providers have arrived and assumed care under the license of
their medical control agent. This also relates to Mike's post. Medics can't
be expected to function effectively if they are supposed to take "orders"
from any Joe Blow who claims to be a physician.

R. Smith, MD

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Ben Reynolds
Sent: Tuesday, April 11, 2006 12:48 PM
To: Trauma &amp, Critical Care mailing list
Subject: RE: In regards to EMS intubation issues

He may not be able to order the paramedics to intubate (or do anything for
that matter) but he certainly could have taken medical custody of her from
the paramedics if he saw it fit.  

In most states, once a physician (no matter what flavor, whether emergency
physician, dermatologist, psychiatrist, whatever) prescribes a course of
care they are legally and ethically bound to see it to it's finality until
they are relieved by another physician.
 This requirement is not satisfied until the receiving physician has
PHYSICALLY encountered the patient at his or her facility.  These are the
tenets on which laws governing interhospital transfers (EMTALA) have been

The same holds true for people needing medical attention outside of the
hospital or on the street.  A physician is held to a higher standard of care
than the average good samaritan; a common reason why civil suits against
"good samaritan" physicians or nurses go forward with such success.  

Calling an ambulance to the physician's office or to an urgent care center
and handing over a patient whose condition has unexpectedly changed to a
paramedic doesn't absolve the transferring physician of medical
responsibility if the patient's condition worsens enroute, even if the
argument that it was the "right thing to do" holds true.  Conversely, the
medical control physician approving a course of treatment for the paramedics
on the patient being transferred does not make the receiving physician
liable because the "physical contact" requirement hasn't been satisfied.

This urgent care physician in this case was obviously pretty savvy:

1.  He did not take the patient into his facility to examine her and
initiate a plan of care on her, thus it is debatable whether the patient was
ever really "under his care".

2.  He only "offered" his assistance to the paramedics, which was refused
without physically intervening himself.  

Thus the paramedics are up a creek without a paddle. 
If the facts of this particular case had been the same with different
circumstances (ie patient with same problem but WASN'T picked up out the
parking lot of an urgent care center and a physician HADN'T been
involved) the outcome would probably have been different.

Ben Reynolds, PA-C
Pittsburgh, PA  


--- Robert Smith <rfsmithmd at comcast.net> wrote:

> Great points. I'm confused about several of the facts as stated also. 
> For one thing I'm acquainted with Frank and have always considered him 
> a strong EMS advocate. Not only do I have doubts about the Urgent Care 
> doc being set up to intubate, he certainly couldn't "give orders"
> to the medics as he is
> not part of their medical control.
> Rob Smith, MD
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org]
> On Behalf Of Jeffrey Leach
> Sent: Tuesday, April 11, 2006 8:05 AM
> To: trauma-list at trauma.org
> Subject: In regards to EMS intubation issues
> According to the JEMS article, Etomidate is described as a paralytic, 
> when in fact it is an induction agent. While etomidate would be 
> appropriate to administer in this case, it may or may not relax the 
> Pt. enough to accomplish intubation. A true paralytic would have 
> solved the problem of a "
> clinched jaw ". If the Paramedics in this case did not have a 
> paralytic per protocol, one must wonder if the Urgent Care Facility 
> Physician could have facilitated intubation with a paralytic drug. In 
> regards to the documentation issue, we should all remember that if it 
> is not documented, then it was not done...
>                   Jeffrey P. Leach, EMT-P
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