I am a physician at a critical access hospital. I manage both the ER and inpatient service and am the only physician in the hospital. This is the reality for many rural hospitals across the country. With no urgent care in town, and with primary care offices few and far between, these hospitals see everything.
We see patients with ailments from a minor finger laceration to those with septic shock from a bowel perforation. Lacking a designation of any kind, we are not typically brought patients who have emergent signs of stroke, heart attack or trauma by EMS. However, patients do have the right to choose which hospital they want to be brought to(or not brought to). Also, patients with these ailments can walk in at any time.
EMTALA law says that we cannot turn anyone away seeking medical care at an ER. To hospital legal, this also means that we cannot suggest they go elsewhere on arrival to our facility, even if it is in the patient’s best interest. EMS also cannot refuse a patient’s request to go where they want to in an emergency, especially if the facility they want to go to is closer.
Therein lies the problem in the current state of hospitals in America. During normal times, these patients can be seen, triaged, stabilized, and transferred in a timely manner to an appropriate hospital. During COVID, however, hospitals are at capacity. Whether because of staffing shortages or simply too many patients needing hospitalization, or both, the end result is the same.
There are certain conditions for which a transfer is always accepted, regardless of hospital capacity. Patients with a STEMI (ST-elevation MI, in medical terms a severe heart attack) needing emergent heart catheterization by a cardiologist are one. Another is those with hemorrhagic stroke(bleeding into the brain needing emergent neurosurgery). At some facilities, ischemic stroke(a blood clot in the brain needing emergent TPA to break it up or following TPA administration given the high risk of bleeding thereafter) also falls into this category.
However, there are many patients who need emergent transfer that do not fall into these neat little boxes. These patients cannot be transferred regardless of hospital capacity. I have seen a huge number of patients with serious acute illness that need specialty care I cannot provide. During normal times, they would be transferred and get the care they need.
With COVID filling hospitals, now bowel perforations needing emergent surgery, variceal bleeds needing emergent endoscopy, small bowl AV malformations needing interventional radiology coiling, vaginal bleeding following spontaneous abortion requiring D+C by an OB/GYN, limb ischemia needing vascular surgery, hydrocephalus causing acute mental status change from outflow obstruction needing neurosurgery, acute compressive myelopathy needing neurosurgery are just a few of the emergent conditions I’ve seen and treated and had to wait sometimes days for transfer.
That is days of potential permanent neurological loss, including loss of motor and sensory function, brain damage, and possible loss of bowel or limbs. Not to mention the increased risk of death for some of these conditions should we not be able to slow and replace the loss of blood fast enough. I have had two patients die awaiting transfer. I cannot say whether they would have survived if they had been transferred, maybe and maybe not. I do not know the fate of those I transfer most of the time, and it’s very possible a long delay cost them their lives at the receiving facilities too.
Any number of preventable deaths is too many. That is why I think EMTALA is now failing the people it was established to protect. Suppose the hospitals in a four state area are at capacity and have no beds for transfer acceptance. In that case, physicians and EMS should have the ability to be honest with patients in order to provide the best care possible.
“The Emergency Medical Treatment and Labor Act (EMTALA) requires hospitals with emergency departments to provide a medical screening examination to any individual who comes to the emergency department and requests such an examination, and prohibits hospitals with emergency departments from refusing to examine or treat individuals with an emergency medical condition.”
A critical access hospital with no specialty backup is not the place to await transfer for days for an emergent surgery. If a patient who has been throwing up blood for days and who is white as a ghost walks up to the window, doing an initial triage and starting appropriate medications before having EMS transport the patient on fluids to the appropriate hospital 45 minutes away for blood and emergent GI evaluation (with a physician to physician call to prepare the receiving hospital) is going to be safer for the patient than waiting the same amount of time for blood to be prepared and then waiting days for transfer.
Similarly, EMS should have the ability to override a patient decision on which hospital they would like to be taken to if it is in their best interest. A patient with a black and cold lower extremity should not be taken to a facility without vascular surgery just because they don’t like a particular hospital. And suppose the ambulance does arrive with a patient like this, as long as the patient is stable after an initial triage. In that case, the physician should be able to have EMS continue on to the next appropriate facility.
This initial triage, I believe, would meet the requirement of a medical screening per EMTALA and allow EMS to continue on to the next facility lawfully. However, this would require a change in hospital and EMS workflow and how many hospitals interpret EMTALA. It may perhaps require a change in the law itself and take circumstances into consideration. However, such a change is necessary to preserve life, and that above all should be our goal as physicians.
Trent Dietsche is a family physician.
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