Sometimes we should refuse transfers

Almost once a month, I see in my Facebook feed a link to the article from several years ago in which a Florida ambulance service was ordered to pay a 10 million dollar settlement to the mother of a baby that was born in the back of one of the service’s ambulances. The mother was being transferred from one hospital to another, due to the patient’s (apparently) precipitous labor. The mother’s water broke, and the baby was delivered (and heroically resuscitated) in the back of the ambulance. Unfortunately, the baby suffers from cerebral palsy, and a jury in Florida found that the ambulance service was liable for the injuries to the baby, because they did not have the appropriate equipment on board.

I trust that the story is easy to find, and has been read by the majority of us already, so I won’t link to it here.

I’ve argued that the service never should have taken that transfer in the first place, and that the service is most certainly liable.

Most of the Facebook comments on these threads follow a common pattern; that: 1) the paramedic performed a heroic thing by resuscitating a 25-week fetus, 2) the ambulance crew should have called their supervisor or medical direction prior to taking the call, 3) shock that an ambulance service would be held liable when they saved a very difficult patient, 4) the plaintiff must be money-hungry, and 5) the ambulance service should have demanded that a hospital employee ride in the back of the ambulance with the patient.

I will never argue with anyone on the first point. I know several people who work for EVAC, though not this particular paramedic. I can only imagine the difficulty this paramedic encountered when faced with having to resuscitate a pulseless, apneic 25-week fetus with only the help of their EMT partner. This was very strong work by an EMS crew, with a much better outcome than would have occurred in a lot of other situations.

I don’t agree with calling a supervisor or medical direction. Calling a supervisor for guidance would be only minimally helpful, and a medical director phone call does nothing to remove liability from the providers. This ambulance service was most certainly liable, from the actions of the call-taker to the paramedic who accepted the transfer.

All too often, if the paramedic had refused to take this patient (as some would), they would be viewed as a “problem” employee who was “refusing to run a call.”

To address point number four, I don’t believe the mother of the baby is “money-hungry” in the least, but that she is now faced with paying for a lifetime of care for a baby who suffered injury at the hands of the ambulance service.

And to address the final point, asking for a rider from the hospital only provides the paramedic with another pair of hands. Hospitals (in my experience) are hesitant to send riders for several reasons. First, because they lose the nurse for several hours, and staffing levels are affected negatively. Second, many nurses are not protected from liability when they leave the hospital grounds. Nurses operate under a physician while in the hospital, much like paramedics operate under a physician while in the ambulance, which begs the question; which physician does a nurse riding along operate under?

Several years ago, I was called in the middle of the night to a small, rural hospital to transfer a patient to a very large hospital that was more capable of taking care of him. The patient was incredibly sick, with a PaCO2 in the 90s, with a PaO2 in the 70s. This patient was on BiPAP, and the sending hospital was absolutely bouncing off the walls to get him out of their hospital. While I was working on a critical care truck, my ventilator at the time did not have the capability to provide BiPAP. I informed the sending physician that I wasn’t able to transfer this patient in this condition, and he was apoplectic. The sending hospital was not in the position to send their BiPAP machine with me in the back of my ambulance, as it was the only one they had, and they couldn’t be without it for the 5 hour round trip.

While the physician was incredibly mad at me, I stood my ground, and he finally asked what needed to be done to have the patient transferred, and we discussed the case. The patient was sedated, paralyzed, intubated, then placed on my ventilator for the transport, which was uneventful.

When I got back to the station in the morning, my supervisor called me into the manager’s office to discuss the call. The phone call they received from the sending physician led them to believe that I did not want to run the call, and that I was rude, and incapable of handling a patient on BiPAP. After explaining the potential liability that the company would face had I transported that patient as he was, everyone agreed that I did the right thing.

I was fully prepared to walk out of that hospital that morning without a patient. I act in the patient’s best interest first, as we all should, but I also keep in mind the company’s position. Those two don’t have to be in contrast to each other. If we act for the company first, by taking the call because it is a paying patient, then that is not always in the patient’s best interest. If we do the right thing for the patient, then the company will, more often than not, be okay.

Comments

  1. I was called to a small community hospital to transfer a patient to a large university hospital nearly 300 miles away. The patient had a 3cm, actively dissecting, thoracic aortic aneurysm and the sending facility did not have the surgical capability to repair the patient’s TAA. The patient had uncontrolled hypertension, and despite being medicated with 50mcg of Nitroglycerine per minute, the facility had been unable to get his systolic blood pressure below 200mmHg. The sending facility had maxed him out on the Nitro, and were unwilling to consider Esmolol or Labetalol as a [I thought more effective] means of controlling his blood pressure.

    I was immediately wary of the transfer due to the nature of the condition. In the event that he had deteriorated en route, there was literally NOTHING I would have been able to do for him. It would have just been him, my EMT partner, and I, on the side of the interstate somewhere in the middle of a cornfield. The fact that the sending facility was unwilling to change his anti-hypertensive medication to something that would be not only more effective, but without the reflex tachycardia associated with Nitro, more or less made the decision for me. I called my medical director anyway, and his response was to refuse the transfer and to leave the hospital immediately.

    My supervisors were very upset and accused me of not wanting to take on the burden of a long-distance transfer. It was only after explaining the circumstances, and emphasizing the fact that I had had medical control orders to NOT take the patient, that the dogs were called off.

    Unfortunately, like you said, there are just some circumstances that are beyond our capabilities to manage. Even working Critical Care, there are occasionally patients that are flat out beyond my abilities to keep stable. In those cases, for the sake of my own conscience, my personal and professional liability, and the liability of my employer, I am forced to politely decline. The hardest part about that, for me at least, are the times when I am forced to explain to the patient why I cannot take them to the facility that can give them the medical care they so desperately need.

  2. Skip Kirkwood says:

    The immediacy of such a call is difficult. Leaders in EMS organizations should be prepared to support their medics when they make “difficult but unpopular” decisions in the best interests of the patients and their service.

    Here’s a hint for the service – if everybody else involved settles the lawsuit, you should settle too. Don’t be the only one “left standing” for the trial – for you will get to bear the wrath of the jury, no matter who else might share the blame.

    Unfortunately, too many medics actively work to “dodge calls.” This prejudices the minds of supervisors and managers – it’s hard to support one difficult but unpopular decision when the last seven complaints have been medics who tried to get out of a call for reasons only related to one interest – the medic’s interest in doing something besides running the call.

    • Leaders in EMS? What leaders in EMS? There are a lot of managers in EMS, but very few leaders. The managers consider medics and EMTs expendable and easily replaceable. Thus they pressure them to take every patient, not worrying about potential liability for those fortunately rare, high risk patients.

      As related in the post and comments, the reflexive response was to call the medic on the carpet with the presumption that the medic was a lazy slug. In most cases, I’d call that projection as very few really ambitious and competent medics end up in management, but slugs do.

  3. Skip Kirkwood says:

    There are plenty of good folks in EMS who try to be good leaders. And it is difficult – particularly in the absence of good followers – but that really is another thread.

    In looking at court cases, it is important to seek out “the law of the case” – the actual lessons to be learned from what happened – not just the sensational news story that somebody not aware of the facts and the law writes.

    In this case, the lesson is not about “refusing the transport” or not. It is about the status of the case, and who is settling what. The moral of the story is that “If the doctor settles, the hospital settles, and everybody else settles, the EMS agency should not decide to be the last one standing.” Settle – write a check – don’t go to trial by yourself, and be there with a sympathetic mom and a dead child. The jury will slap you silly if you violate this rule.

  4. We have hospitals that send personnel on transfers where they aren’t necessary- If they are, they’ll fill the truck with them. I saw one pull in one day with two firefighters, two nurses, and an RT in the back. The nurses were even carrying extra sedation meds from the ED’s supply and a standing order from the transferring MD to use them as necessary.

    Fortunately there is now a critical care service in the area run by the trauma center that takes care of most of the “OMG” runs. Two CC medics and a doctor- not much they can’t handle.

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