Scott Adams said that everyone is an idiot about something. A co worker of mine used to say, “You can be smart or you can be a doctor.”

The same concept, which is that people can be brilliant in many respects while exceedingly dumb in others.

Note that I am not a lawyer and this is neither a legal opinion or legal advice. It’s just a story from reviewing reports.

Which brings me to today’s story.

I reviewed an ambulance report where the crew was dispatched to an unconscious patient. When they arrived they found a conscious patient that may have had a seizure, but maybe didn’t. The patient, a man in his late Thirty’s had no history of seizures, had no history of syncope, and in fact had no medical history at other than one similar episode some time in the past.

The patient attributed whatever happened to his blood glucose level being low. A quick test with a glucometer revealed that it was fine. Vital signs were checked, which in acceptable ranges. A 12 lead EKG was obtained, which was also fine. A Stroke Exam was negative.

The patient agreed to be transported to the hospital for a more complete examination by a physician. Which is the best thing to do under these circumstances.

Along the way to the hospital an IV was started just in case something happened that required medication. Vital signs were repeated and another 12 lead EKG was obtained. Which was identical to the first one.

Then it started to go sideways. As the ambulance arrived at the hospital, the patient had a change of heart. He decided he didn’t need to be examined in the hospital, he just wanted to go home.

This put the EMS crew in a bit of a situation. They had initiated care and had transported to a hospital per their protocols. Now, the patient had thrown a curve ball at them. They contacted the Emergency Department and asked for a doctor to come out to the ambulance.

In a minute the doctor in charge of the Emergency Department came out, talked to the patient, looked at the EKG print out, and then told the paramedics it was okay for the patient to refuse. The patient signed a refusal, the IV was removed, and he left.

Pretty routine except for one problem. YOU CAN’T DO THAT! At least not in the state where this occurred and it appears to be a violation of a federal health care law.

The Emergency Medical Treatment and Active Labor Act (EMTALA) was passed in 1986 after a series of cases across the country where hospitals, mostly for profit hospitals, refused to examine and treat patients who came to their Emergency Rooms seeking treatment. Mostly it was because said patients were indigent and couldn’t pay. After a couple of these patients, one a woman in labor, died Congress took action.

The American College of Emergency Physicians (ACEP) is an organization that is dedicated improving in hospital emergency medical care. They publish a lot of guidelines and information for emergency physicians.

This is one of them,  Understanding EMTALA. It’s pretty thorough and here is one section that explains the obligation of Emergency Departments and medical staff,

Physicians can get penalized for refusing to provide necessary stabilizing care for an individual presenting with an emergency medical condition or facilitating an appropriate transfer of that individual if the hospital does not have the capacity to stabilize the emergency condition.

Hospitals have three main obligations under EMTALA:

1. 1. Any individual who comes and requests must receive a medical screening examination to determine whether an emergency medical condition exists. Examination and treatment cannot be delayed to inquire about methods of payment or insurance coverage. Emergency departments also must post signs that notify patients and visitors of their rights to a medical screening examination and treatment. Signage that could deter patients from seeking emergency care could be an EMTALA violation.
   2. If an emergency medical condition exists, treatment must be provided until the emergency medical condition is resolved or stabilized. If the hospital does not have the capability to treat the emergency medical condition, an “appropriate” transfer of the patient to another hospital must be done in accordance with the EMTALA provisions.

• Hospitals with specialized capabilities are obligated to accept transfers from hospitals who lack the capability to treat unstable emergency medical condition.

While the doctor may have thought that this met the requirements, it didn’t.

First, a patient is considered by this law and regulations to have “arrived” at the Emergency Department when the ambulance is on the hospital property whether or not it has stopped at the ED. The hospital “owns” the patient now.

Second, the hospital not the EMS crew is responsible for documenting the conditions of the refusal, the examination, the explanation of the potential risks of not allowing examination and treatment.

There is now NO record that the patient was ever at the hospital other than the ambulance report, which the way it is written contradicts itself by stating in one part that they transported to the hospital, but in another section that the patient refused transport.

Chances are that nothing will happen as the patient decided not to be treated and since the crew documented it as a patient refusal he will be unlikely to receive a bill.

So it’s a violation of the law, but there will be no consequences. Unless, that is, the patient went home and died for some reason. Or even if he went home, became ill and survived.

In which case someone is going to come looking for answers to some uncomfortable questions. One of which is why didn’t the EMS crew wheel the patient into the ED and let him tell the nurse at triage that he didn’t want to be seen? At which point the EMS crew had fulfilled it’s duty to treat and transport.

I could, at least as a worst case scenario, get sticky from there for the doctor.

It’s very surprising, I might even say astonishing that an Emergency Physician would not understand his obligations under EMTALA. I’m not surprised at the EMS crew asking him to come out and look at the patient. EMS providers aren’t usually well versed in EMTALA, but the doctor should have told them to bring the patient in so that he could comply with the law.

Sometimes, efforts to cover one’s derriere result in doing the exact opposite. This seems to be one of those cases although it’s likely nothing will come of it. I sent the call on to the system medical director for his review. I hope he doesn’t hurt his head too much when he bangs it on his desk.

If it does go anywhere, the hospital risk management team are going to get Agita.