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In regards to EMS intubation issues

Robert Smith RFSmithMD at comcast.net
Wed Apr 12 21:34:16 BST 2006


I agree with what everyone said today. I think the language cited in
Ashton's and Doug's posts is especially clear and appropriate.

I do think that each institution will have its own protocols regarding how
and when they receive a patient and when they have assumed responsibility of
care and that was specifically addressed in some of the regs.

Obviously the transferring doc and institution are responsible for the pt.
until an appropriate transfer of care is achieved.

Re: "stable" some of the cases cited that I read yesterday made it sound
very stringent for elective transfers. For patients sent to a higher
standard of care I believe it was appropriate when more likely than not that
the transfer would improve the care given to the patient. We have had
discussions before about patients being "too unstable" to transfer. I feel
as a rule of thumb that if they are going to die because the current
hospital can't or won't do what is needed they should be transferred.

Rob Smith, MD

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of docrickfry at aol.com
Sent: Wednesday, April 12, 2006 6:40 AM
To: trauma-list at trauma.org
Subject: Re: In regards to EMS intubation issues

Your assertions as to where responsibility lies in the transfer of a patient
are absolutely correct, and so well established are these tenets I for the
life of me cannot fathom how anybody could be in doubt about it--clearly the
responsibility for transfer, for assuring the patient's safety during the
transfer, and for inititation of the proper treatment, lies solely with the
transferring physician--how can it be otherwise?  The receiving physician
assumes responsibility on arrival at the receiving facility.  This is the
thrust of the entire last chapter of ATLS--very long accepted principles.
EMTALA requires that a patient be stabilized before any transfer, and the
definition of "stable" is that the patient can reasonably be assured not to
deteriorate or die en route.
ERF 
 
-----Original Message-----
From: Ben Reynolds <aneurysm_42 at yahoo.com>
To: Trauma &amp, Critical Care mailing list <trauma-list at trauma.org>
Sent: Tue, 11 Apr 2006 16:47:17 -0700 (PDT)
Subject: RE: In regards to EMS intubation issues


I have no background in law other than being guilty of
several moving violations.  PA-C means "physician
assistant-certified".  

I don't mean to speak or defend the EMTALA law itself,
only what I interpret to be the spirit of it's intent
after having read extensively on it and been the
subject of many lectures regarding it's application at
various institutions, ad nauseum.  Just to be clear, I
am NOT an expert on EMTALA. 

Having said that with regards to your question about
another physician physically contacting the patient, I
believe that act is ABSOLUTELY necessary, otherwise it
could be construed as patient abandonment.  How can an
accepting physician be responsible for a patient he or
she has neither see nor examined?  Is it appropriate
for the receiving physician to accept the diagnosis of
the transferring physician on it's face without having
confirmed it him/herself?  

To better illustrate (if I need to):  A transferring
physician begins a patient on IV thrombolytics for a
diagnosis of "occlusive stroke".  The transferring
physician is wrong and the patient actually has a
subarachnoid hemorrhage.  That is "prescribing a
course of care" which the transferring physician,
confident enough in his diagnosis to begin that
therapy, is ultimately responsible for the
consequences of no matter where the patient ends up. 
The fact that a MISdiagnosis exists isn't the
responsibility of the receiving physician as he or she
wouldn't be able to make corrections without having
seen and examined the patient.  I don't believe that
being "received" by a facility meets that standard.

Regarding your question about the responsibilities of
the transferring physician to the patient's care while
in transit I've included the following from EMTALA
Interpretive Guidelines: § 489.24 (e)(2)(iv):

"...The physician at the sending hospital (and not the
receiving hospital) has the responsibility to
determine the appropriate mode, equipment, and
attendants for transfer...While the sending hospital
is ultimately responsible for ensuring that the
transfer is effected appropriately, the hospital may
meet its obligations as it sees fit. These regulations
do not require that a hospital operate an emergency
medical transportation service..."

Broadly I interpret that to mean that as the
transferring physician you are responsible for that
patients care from door to door even if you aren't in
attendance during the trip, I refer you to my above
response regarding "prescribing a course of care".

Regarding your question about good samaritan
physicians and nurses being sued, that is purely my
own personal belief with no data to substantiate it. 
It is an issue which I've heard discussed on multiple
occasions when a Good Samaritan Act comes up in a
given state.  Personally, I am aware of several civil
suits against bystander physicians and nurses both for
actions taken during a medical emergency.  I regret
that I cannot provide documentation to back up that
biased assertion.  

Ben Reynolds, PA-C
Pittsburgh, PA



  



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

> Ben,
> 
> 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
> based.
> 
> 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
> > --
> > trauma-list : TRAUMA.ORG
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> > 
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=== message truncated ===

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