other people's emergencies: random thoughts of an urban paramedic

For more than twenty years I've worked as a paramedic for the city of Boston, Massachusetts. The opinions expressed in this diary are mine alone, and do not represent the views of Boston EMS. Names, dates, locations, and physical characteristics have been changed to ensure patient confidentiality.

Wednesday, April 22, 2009

Emergency Departments Calling Ambulances for Emergencies

I'm on vacation this week, which means that I don't have any observations to report from the ambulance. In the meantime, an anonymous reader has suggested a topic of discussion. According to a story in the Vancouver Sun, the emergency department staff at a Vancouver hospital refused to assist a man who'd collapsed just ten feet outside the emergency department's doors. Instead, they called for an ambulance.

In the United States, this incident would have fallen within the scope of a federal law, the Emergency Medical Treatment and Active Labor Act (EMTALA). Among other things, this law requires hospitals with emergency departments to screen and stabilize patients who come to their facilities seeking help for medical conditions. Under EMTALA, a patient "comes to" an emergency department once he gets within 250 yards of it, even if he doesn't explicitly request assistance. As long as the patient appears to need treatment, the emergency department must respond.

I don't know much about Canadian health care law. I don't know whether that country has any statutes equivalent to EMTALA. It's possible, then, that a Canadian hospital may have no legal duty whatsoever to help an unconscious man right outside its door.

So, here's the question: What should hospital staff do when it learns of a medical emergency just outside of its facility? Officials at the Vancouver hospital say that these matters are best left to EMS personnel, because they are trained to deal with out-of-hospital emergencies, and hospital personnel are not. But if this is true, then why do doctors and nurses regularly intervene when encountering an emergency on the street, sometimes to the point of wresting control from more experienced EMTs and paramedics? I'm not trying to say that doctors and nurses should not get involved; it's just that both perspectives cannot be true.

EMTs and paramedics: Have you ever dealt with this issue personally? Foreign EMS personnel: How does this work where you live? Doctors, nurses, and other hospital staff: How would you handle this situation? And non-medical readers: Do you have any thoughts about this?

Here's the link:
http://www.vancouversun.com/Health/Hospital+staff+call+ambulance+outside/1517456/story.html

As always, thanks for reading.

30 Comments:

Blogger PGWG said...

I'm not a medical professional, I was just a volunteer at my regional hospital in Alberta, so take this with a grain of salt.

The policy at our hospital was similar to what happened in BC - if somebody was found injured outside of the hospital (parking lot etc.), the procedure was to call 911. The rationale was that hospital staff were not trained for out-of-hospital practice. Something about risks of injury outside of the workplace and not being covered by workers comp, working outside of the scope of practice, and whatnot.

9:01 AM  
Anonymous Anonymous said...

Policy (Mass. hospital where I work)...public areas inside of hospital-911 called,nursing supervisor paged, hospital staff would assist (according to capabilities)- many AED's on walls....outside of hospital on hospital grounds- same as above...except no AED's outside (hospital does have its own paramedics and ambulances)- depending on distance to the ED, they would be transported by stretcher or ambulance to our ED.

11:15 AM  
Anonymous Potassium said...

I don't know what the law says here exactly, in Austria.
But our ambulance-cars are often requested because somebody collapsed AT the hospital. This occurs most at private hospitals or at hospitals whice have large park areas.
What also often happens is, that doctors can't deal with the emergency because they're from the false field. Often we have to come to cardiac arrests because the psychiatrist which is on location can't ventilate or intubate the patient.

12:28 PM  
Anonymous Anonymous said...

Doesn't Canada have nationalized health care?

Wouldn't the patient end up in the hospital anyways?

Isn't the response time significantly degraded that just bring the patient in on a stretcher?

2:25 PM  
Anonymous MassEMT said...

I'm an EMT that works on the north shore of Mass. and I can't tell you how many times I have been called to the parking lot of a certain hospital (I won't use names). The nurses have told me thats its "an insurance thing." I think its ridiculous to tie up our resources when there are perfectly capable people inside just watching us.

2:32 PM  
Anonymous Anonymous said...

Well, in my limited EMS career (EMT-B ride alongs) I have already come across a recently graduated O.R. nurse at an accident scene telling a Paramedic what to do.

She was intoxicated and clearly my Paramedic partner was so agitated with her. Finally, he stood up looked at her and said, "Did you know that according to State Health Statute 186.2b, any off duty health care provider attempting to provide care outside their scope of practice while under the influence of drugs and/or alcohol is a felony and punishable up to 2 years in prison? So, by all means, what should I do here nurse?"

Of course, that "statute" was total BS, but the nurse was stunned and walked away. We got a good laugh on that one, and I learned quickly to not take any crap from anyone, drunk or not, in a Pre-Hospital setting unless you are handing care off to someone above you.

3:04 PM  
Anonymous Lottie said...

I work in a hospital in the UK and we've always been told that if we find someone in the hospital grounds who needs medical care, we have to call an ambulance.

It doesn't really make sense but I guess it must be an insurance thing - if HCPs treat people outside of the hospital but within the grounds or while they're on duty there, then whatever they do is covered by the hospital insurance.

In practice though, I can't imagine anyone getting in to trouble for it, especially if it was an emergency. (it might be different across the pond though!)

3:40 PM  
Blogger Norma said...

I used to work at the front desk (pt. registration) of a community hospital that bordered a large piece of open land (privately owned) where local kids go sledding all the time in the winter. One Sunday afternoon, a teenage boy came running in frantically explaining that a girl had hit a tree. She was, apparently, alert and able to move but in a lot of pain, maybe with a broken limb or something. I called the charge nurse and was told the boy needed to call 911. I'm not sure if the site where the girl was hurt would lie within 250 yards of the building, but it may have been. I called 911 for the kid and the girl was brought in by EMTs shortly thereafter. I guess we couldn't really have a doctor and nurse traipsing down through the snow with a gurney...

4:56 PM  
Blogger Donna said...

Very tiny nitpick -- this actually happened in Saskatoon, not Vancouver (about 1600km difference, but each province has very different emergency response procedures.) This is likely only important to me, because I'm a paramedic-in-training in Vancouver. :)

5:26 PM  
Blogger PGWG said...

Yes, in Canada we have socialist - er, 'universal' health care.

We get what we pay for.

It's not about response time (and the life/health of the patient), it's about following proper procedure.

Or maybe I'm just a bit bitter about our health care system as I want to get an MRI because my knee isn't hurting, but the specialist refuses to order it until I try another couple of months of physio (and then when he does order it, it'll be a 6-18 month wait to get the MRI - and if I was to need surgery, another 6-12 months)

6:35 PM  
Anonymous Mark said...

Hey, I'm an EMT for a private company in Boston, you may have even seen me if you ever swing by the Faulkner, my usual post. In the past 3 or so years I've had a number if incidents in which I was sent to various places around the hospital for injuries.

I actually once responded from the arboretum to the front door for a man with a bloody nose, and when I arrived the BEMS Medics who are stationed there were already assisting the guy. Confused, I asked the supervisor who hangs out there why we were even called and apparently because we have the contract the facility is obligated to call, and we are obligated to respond, even if there are already healthcare professionals on scene.

I've also responded from the dialysis center thats like 100 yards away, and was forced to load the stretcher into the ambulance, and drive 30 seconds to the other side of the parking lot, apparently pushing the stretcher down the sidewalk is too dangerous.

It's very bizarre, hospitals and facilities have crazy rules, and regulations, if only it was all one incredibly well funded, free to the public, EMS system run by EMS personnel...

7:54 PM  
Anonymous Anonymous said...

I know that in several Seattle area hospitals the staff and volunteers are instructed to call a code for anything on hospital grounds regardless of whether the person involved is a patient or not. The code team will respond, attempt to stabilize the situation, and figure out appropriate transport to the ER. I know of a recent resuscitation of a recently discharged patient that began in the parking lot.

12:05 AM  
Blogger TS said...

So, here's what we seem to have learned from this little discussion:

1. Hospitals seem to care more about complying with the provisions of their insurance coverage than in helping someone in an emergency.

2. While emergency department personnel will sometimes go outside the hospital to check on a person having an emergency on hospital grounds, they virtually always call for an ambulance, whether one really seems to be needed or not. This occurs not just in the US, but in the UK and Canada as well.

3. Our Austrian commentator correctly points out that this practice is reasonable in speciality hospitals, such as psychiatric facilities, which do not ordinarily handle medical emergencies.

4. As our former patient registration clerk points out, some situations require special equipment, and therefore must be handled by EMS, rather than emergency department personnel.

5. And finally, hospitals in nationalized health care systems place procedure and statistics ahead of actual patient care. This does not surprise me, as I've heard it from many other sources already.

I'd like to add a few comments of my own.

It seems to me that emergency department staffs take a huge chance in failing to help patients on hospital grounds. Federal law always requires, at minimum, both a screening examination to determine whether an emergency condition exists, and care to stabilize such conditions. Hospitals that fail to provide these services may be fined by the Department of Health and Human Services, and they may be barred from accepting Medicare reimbursement. And, of course, violations of these obligations can serve as the basis of a lawsuit by the patient.

Hospitals cannot get out of EMTALA liability by claiming that their insurance does not cover such activities, or that workers compensation will not cover their employees. In the United States, at least, when a patient needs help on hospital grounds, and the emergency department staff knows about it, they have to respond.

It's troubling to hear that so many hospitals will resort so quickly to calling 911 for emergencies on their own grounds. As I've said so many times before on this site, the public must sometimes be forgiven for utilizing EMS resources inappropriately, because ordinary callers to 911 don't always know how EMS is supposed to work. But emergency department staffs should know better. They deal with EMS all the time, so they should know better than anyone how scarce EMS resources are. Calling for an ambulance unnecessarily might make the hospital staff feel better, but it jeopardizes lives, and that's not right.

This has been an interesting exercise. Thanks for playing along. I'm going to take a couple of days off, and then I'll post some new material.

1:01 AM  
Anonymous Anonymous said...

I work just north of Boston and was called for an emergency in the parking lot of the local hospital when I was but a shiny new EMT. Confused, we responded over to find a woman passed out in the front passenger seat of a car pulled up in front of the ER entrance. A security guard standing nearby said, "Yeah, a nurse came out and checked her out. Then called you guys. She has a pulse!"

At this point, my partner and I were very confused and somewhat upset (I know I at least had EMTALA drifting through my head). The patient didn't twitch for vigorous sternal rubbing, but was breathing and indeed had a pulse. To be honest, that was about all the assessment we did. Why take more time on scene when the ER is RIGHT THERE? We hauled her onto the stretcher and wheeled her in.

Later, when the supervisor came up, we ended up the bad guys. Apparently, when the nurse came out, she did the trick where you lift their arm above their head to see if they'll allow it to fall and hit themselves in the face. She determined that the patient was just faking the whole thing and went back inside to call us. Apparently we were called because per my supervisor, "the hospital does not have the tools and training to do patient extrication from vehicles." (Note that there was no suspected trauma and she was simply bodily pulled from the car. Also note that the hospital keeps an old Ferno stretcher where they put extra EMS boarding equipment, not 50 feet from this car).

I'll buy the extrication thing as an overall concept. Fine. But my question then (and still now), is whether or not there was a question of abandonment. The nurse made contact. Whether or not she determined the patient was legit, she still made contact and then walked away. Our response time was 3 minutes total. Would it really have been so hard to wait? Or even come back out when she heard the sirens? Just a simple heads up of "hey, this is what *I* found" would have gone miles in this situation...

9:59 AM  
Blogger TS said...

Anonymous:

That kind of story has the same kind of effect on EMS personnel that a car wreck has on the public: It's horrible, and it disturbs us, yet we can't look away from it.

It's infuriating to think about how badly some people abuse the EMS system. It's even worse when this is done by health care providers who should know better.

The facts you provided certainly suggest that abandonment occurred. The question then becomes one of damage. Was anyone actually harmed by the nurse's decision to walk away from the patient? In this case, the answer appears to be "no." In a lawuit, as in the game of playground basketball, when there's no harm, there's no foul. This doesn't mean that it was okay for the nurse to do what she did. Nothing can really be done about it in court, however, because nobody suffered any damage.

1:37 PM  
Blogger Last Angry Man said...

TS (or anyone else well-educated in this); I'm very curious:

Despite all of the previous good information, isn't there a clause or law that says that if a medical emergency occurs, any nearby medically certified professional must intervene?

I'm really wanting to know, as my staff and self would on occasion intervene in local medical emergencies near my workplace (City Hall Plaza/Court Street). Sometimes we'd catch them occurring on the all-around security cams, sometimes someone would run in the door and tell us.

Being CPR certified, we were to the understanding it was a violation of law for us to observe an emergency such as that, and not intervene.

A sort of reverse "Good Samaritan" rule, is it not?

And we did intervene multiply. One of my co-workers (Boo Yah, Bud!) won several awards from the Governor on down, for doing so on a stricken person, using our portable defib. (in front of Staples).

So which is legally correct? Were we to jump right in, or merely wait for EMS/Paramedics?

Really curious.

1:47 PM  
Anonymous thisoldwomanisonlyagirl said...

to Last Angry Man:

i took a one-day red cross course at my workplace. the instructor informed us that our legal obligations in the event of an emergency depended on whether than emergency happened at the workplace/work-sponsored event vs. a non-work location when we're off the clock. apparently, because we were participating in this training at the workplace, at the expense of the employer, and for the main purpose of assisting in any emergency situations at work, we were ONLY legally obligated to help out in an emergency that occurs in a work setting. apparently, i could walk right by someone having a cardiac event in a grocery store w/o any legal consequences, even though im trained in cpr and the use of a defibrillator. (which of course i would never do).

ts, what does the atty think? was my instructor correct? im sure that depends on state statute/case law anyway...

8:13 PM  
Anonymous Anonymous said...

At BMC we have a "proceed out team" which responds to incidents in and outside of patient care buildings. As you are probably aware, they frequently call EMS to help transport patients from some outlying buildings. One ER nurse, an ICU nurse and a medical resident are usually on the team and can call the code team if needed.

Personally I am disgusted by the story you included from Vancouver. It seems to me a serious ethical and moral failure to be willing to ignore such a patient while waiting for an ambulance to respond.

This policy also represents a serious lack of thought regarding productive and cooperative work relationships between EMS and a hospital's emergency department. Calling an ambulance for a patient that is immediately outside of an emergency department creates extra, unecessary work for EMS responders and takes ambulances out of service that might otherwise be available to respond to actual emergencies.

2:44 AM  
Anonymous MichiganEMT said...

Late last year there was a case in st.Petersburg, Florida where a man collaped of a heart attack 100 feet from the emergency entrance to the VA hospital. The ER staff refused to treat the man or to even let him into the ER because he wasn't a veteran. The staff called an ambulance to transport him to Bayfront Medical Center, also in St. Pete. According to the article in the St. Petersburg Times, this has happened several times at the VA Hospital in Pinellas County, Florida.

3:19 AM  
Anonymous Anonymous said...

I have a very different perspective on this, I work for the US Government in the Marine Domain and when working with the AMVER program (Automated Mutual Assistance Vessel Rescue System) have seen ships divert hundreds of miles off course to provide more advanced medical care to other ships at sea. One story in particular involved a well known ocean liner on a Southampton UK- New York run (and these guys keep a VERY tight schedule due to the coast of operating a ship that size) divert over 11 hours to assist a tanker with crewmember that suffered a traumatic brain injury to far away to stage a helo rescue because the ocean liner had a doctor and the tanker did not. After conducting a very hazardous transfer of the crewman by small boat the ocean liner made best speed towards the US while the liners medical team kept the patient stabilized until the Air Force Para-Rescue (PJ’s) unit out of Long Island made a trip (with multiple airborne refueling) out to pick up the victim and deliver them to a hospital on Long Island.

And you mean to tell me that some places will not walk out the front door to render assistance? Asinine.

3:38 AM  
Blogger TS said...

Last Angry Man:

In general, the answer is no. In most parts of the United States, nobody has an obligation to help anyone else, not even when the emergency is medical in nature and the would-be rescuer has medical training.

Without turning this post into a medical malpractice lecture, a patient must prove four elements to win a malpractice claim against a health care provider. The provider must have a duty to act; he must breach that duty; he must cause harm to the patient; and the breach of duty must constitute the legal cause of that harm. Unless the patient proves all four of these elements, the health care provider has no liability.

Vermont and one other state (I forget which one) have enacted laws requiring every person to render assistance to anyone who obviously needs it. Failure to do so does not even constitute a crime. The penalty is a $100 civil fine.

In all other states, the health care provider is free to walk away. This is true whether the would-be rescuer is certified in CPR or a board-certified neurosurgeon. There may be a moral obligation to act, but there is no legal one.

Without a duty to act, the patient cannot possibly win a lawsuit against the health care provider. The case will be dismissed almost as soon as it starts.

A health care provider always has a duty to act when the duty is part of his job, however. A paramedic has a duty to act when he responds to a 911 call. Similarly, doctors and nurses have a duty to act when an emergency occurs in or within 250 yards of their emergency department.

There are other exceptions to the "no duty" rule. Voluntarily rendering aid creates a duty to continue that aid until the situation is corrected or responsibility is turned over to someone else. Ceasing aid prematurely constitutes abandonment. When this happens, the health care provider becomes liable for all damages resulting from the withholding of care.

Also, it's important to note that some countries require all persons to render aid to the best of their abilities in an emergency. This is especially true in European nations. There, a doctor or nurse may indeed become liable for ignoring an emergency.

Good Samaritan statutes protect health care providers who render aid. Every US state has such a law, which says, essentially, that a patient cannot successfully sue a trained health provider who attempts to help, even if he does so negligently. These are curious statutes, unfortunately, because, as state laws, they vary significantly from one jurisdiction to the next. In some states, they afford protection only to providers who render assistance with no duty to do so. The idea, of course, is that people will be more likely to volunteer their services if they know they cannot be sued. Incredibly, some states give Good Samaritcan protection only to health care providers while they are working, which seems to defeat the purpose of the whole thing.

In any event, Good Samaritan statutes generally do not create a duty to act. Rather, they protect those who try to assist in an emergency, but make a mess of it.

Great question. Thanks.

10:02 AM  
Blogger TS said...

Thisoldwomanisonlyagirl:

That is absolutely correct.

10:03 AM  
Blogger TS said...

Anonymous BMC employee:

THANK YOU!

Those are fantastic points. I was afraid that hospital personnel would read my post and the ensuing conversation and think, "That paramedic just loves to find fault with nurses and doctors."

That's not true. I have a fantastic relationship with the overwhleming majority of the hospital personnel I interact with. But wrong is wrong. You said that you were "disgusted" by the "ethical and moral failure" of hospital staff to put procedure and insurance considerations ahead of a patient who obviously needed help. I couldn't agree more.

(BMC, for those readers not from Boston, is the Boston Medical Center, a major teaching hospital and trauma center in the city.)

10:10 AM  
Blogger TS said...

MichiganEMT:

Under EMTALA, specialty hospitals, such as psychiatric facilities, can legally turn medical emergencies away. So can hospitals that do not have emergency departments. That's why you saw many hospitals replacing their "Emergency" signs with ones that read "Urgent Care" during the past few years. In doing so, they hope to put themselves outside the scope of EMTALA.

But a sign isn't the only way to incur a duty to treat emergencies. Any facility whose business is comprised of 30% unscheduled emergencies has EMTALA obligations, no matter what it calls itself. The same holds true of facilities that "hold themselves out" as emergency treatment facilities, by, say, advertising that they are a good place to go when you have a heart attack.

EMTALA prohibits hospitals with emergency departments from delaying treatment to inquire about insurance status. I'd have to know more about the facts, and double-check some aspects of the law, but my initial sense is that a VA hospital--if it has an emergency department--would violate EMTALA by checking insurance in the form of an inquiry about veteran status.

10:21 AM  
Blogger TS said...

Anonymous US Government employee:

That is a FANTASTIC story! It really does drive the point home.

Thanks for telling it!

10:24 AM  
Blogger brendan said...

I'll see your "ED parking lot 911 call," and raise you.

Outpatient surgery center in a building physically connected to the ED of a Level 1 trauma center (employees of both are all employees of said Level 1 trauma center) center calls 911 for a cardiac arrest.

Fire department arrives, assumes care, and wheels the patient on the hospital gurney down one floor and forward 500 feet to the ED.

11:12 AM  
Blogger Last Angry Man said...

Excellent, and thank you for all of your kind answers to my question.

12:29 PM  
Anonymous Anonymous said...

I just wanted to add one other thing. Overall, I think it's too bad that this appears to be general policy but one also has to consider the we now live in an (overly I would argue) litigious society.

Many attorney's make a good living out of "policy". It's a sad truth but just trying to add a little of balance to the discussion. Not saying the policy is right or prudent but it's something to think about.

8:52 PM  
Blogger TS said...

True.

8:23 AM  
Anonymous Anonymous said...

I'm an EMT-A (like an EMT-I to you folks) and have worked hospital security for several years.
Where I worked, the person who discovered the patient could do whatever a lay person could (CPR), unless they were an MD. The only thing that couldn't go out the door was the 'code team', that is to say that beyond the demarkation of the door it was all EMS.
I totally hear ya though...
I was once on a call (inside the hospital) and a patient was involved in a fall from about 8-9 feet, and the code team was called. They didn't know the first thing about spinal immobilization...they taped his head to the wrong end of the board (first) with water-proof/plastic tape. Thank God he didn't actually have a c-spine injury.

8:15 AM  

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