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ED Perspective: Paramedics/Physicians Sued for Inappropriate Transfer

Discussion in 'Emergency Medicine' started by southerndoc, May 25, 2010.

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  1. southerndoc

    southerndoc life is good Moderator Emeritus Lifetime Donor

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    This is being discussed in this thread in the Pre-Hospital forum:http://forums.studentdoctor.net/showthread.php?t=729600

    While the majority of the award was for the EMS service and paramedic ($10 million judgement against them), the physicians and hospitals involved settled for $1.5 million.

    Here's the article:

    I'm curious what other ED docs would do:

    1. Would you have transferred this patient?

    2. Does the medical care provided violate EMTALA?

    3. Does the medical care provided by the ED physician and OB meet standard of care?

    4. Does the medical care provided by the paramedic meet standard of care?
  2. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    Yes. If I have no OB and no monotoring equipment and no preemie equipment a transfer is indicated.

    No. The patient was given a screening exam and it was determined that the patient needed a higher level of care. An appropriate transfer was arranged and undertaken.

    Yes. I don't know any EPs who would have been comfortable managing a 25 weeker like this. Anyone in a similar situation would have transferred.

    The medic did an impressive job of delivering the breech baby (25 weeks helps but still) and resuscitating it. It's impressive the kid lived at all.


    I think it's pretty clear this is a situation where you have a very sympathetic plaintiff. The kid is now going to require a lifetime of care. Juries react to that and happily hand out other people's money. I'm sure that's why the hospital and the doctor settled. I'm not saying it's right. I'm just saying it happens. It's tough to judge anyone who settled on this because if they fought it they'd be bankrupt and never practice again.

    I do think that the hospital and ambulance service should close, tell the local population to stuff it and call the members of the jury, the plaintiff's attorney and the plaintiff when they need medical help.
  3. southerndoc

    southerndoc life is good Moderator Emeritus Lifetime Donor

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    docB, I feel the same way as you. I have a hard time accepting that the paramedics did not provide standard of care.

    The thing that's more disgusting than the amount awarded by the jury is that some pay-for-hire "expert" witness testified and supported this case. For him or her to say the paramedic violated standard of care, unless there are details we do not know, is not consistent with what we consider standard of care. I hope the defendants sue the expert witnesses. Let them spend some of their testimony reimbursements on defending a lawsuit. Malpractice insurance doesn't cover expert testimony.

    Every physician who has a lawsuit supported by an expert witness should sue that expert witness if he/she testifies to things that are not consistent with normal practice or standard of care.
  4. Flopotomist

    Flopotomist I love the Chicago USPS

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    I am curious what proposed course of action the plaintiffs wanted. They argued that the paramedic did not make an appropriate initial evaluation in accepting the physician-ordered transport - but what did they want the medic to do? Refuse the transport? Sit in the original hospital until after the baby was born and THEN transport?

    My question in all of this - could this lawsuit have been avoided had there been a more explicit protocol written outlining when medics accept transfers, or had the original hospital sent a staff member along with the ambulance (although if they are so small that they don't even have OB, I doubt that there are extra ED docs floating around that can go on ambulances).
  5. Stitch

    Stitch Jedi Ninja Wizard Moderator

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    There's an interesting discussion going on in White Coat's Callroom. There are a couple of plaintiff attorneys commenting as well.

    People seem to feel that the transferring meds in the ambulance ought to have refused the transfer and the fact that the woman was about to deliver was 'missed' by the EM physician. I'm not sure what other options there were, however. Let her deliver in the ED where you don't have the proper equipment (umbilical lines, a 2.5 ETT, surfactant and a neonatal vent)? Seems you could be faulted and sued for taking that action as well.

    I've resuscitated lots of premie neonates during my peds residency. Even having the resources of a neonatologist and NICU with NICU RTs right there, the mortality for these patients is around 50%. Long term neurological problems such as CP and MR are much higher than that for those that survive (close to 90%, especially for less than 1000 grams). The fact that those medics saved the kid's life attest to the good job they did.
    Last edited: May 25, 2010
  6. southerndoc

    southerndoc life is good Moderator Emeritus Lifetime Donor

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    Unfortunately this is a lose-lose situation for those involved. Transfer the patient, and they got sued. Don't transfer the patient, and they would've been sued.

    Lawyers really are the scum of the earth. The physicians, nurses, and paramedics involved had nothing but the best intentions for the patient and her newborn. The lawyers seem to have the "thanks for caring, now pay us" philosophy. In other cultures around the world, people actually value you helping them and wouldn't think to sue you unless you really screwed up badly and almost on purpose. Not in America. Even a bad outcome with the very best care available at the time can end with a judgement against you.
  7. WilcoWorld

    WilcoWorld Senior Member

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    I am at a loss for words (an uncommon occurrence for me) over the injustice of this decision.
  8. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner

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    I personally take offense to the attorney saying "because they didn't settle, we hammered them". Sure was caring for the family there. Hope nobody else needs transport soon.
  9. Dwindlin

    Dwindlin SDN Gold Donor Gold Donor

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  10. Arcan57

    Arcan57 Junior Member

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    BS. Complete BS. But there's no need for tort reform...
  11. Stitch

    Stitch Jedi Ninja Wizard Moderator

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    I think it's more than just lawyers and tort law though. These cases succeed because some slime bag MD testifies that the standard of care was not met. Our professional societies as a whole do nothing against these people for it. For our part we need to police our own to some extent and the testimonies of these 'guns for hire' as it were ought to be scrutinized and evaluated. If they are providing inappropriate testimony, then we (ACEP, the AAP, whatever) should take action and destroy their credibility.
  12. southerndoc

    southerndoc life is good Moderator Emeritus Lifetime Donor

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    I like the comment from Skip who said if given the choice, he would prefer specialists brought to him.

    I'm not sure at the hospitals where everyone else practices, but at my hospital it takes about 6 months to get credentialed and at least 72 hours to get emergency credentials.

    So Skip and his family members will be waiting a long time to bring the specialists to him if they aren't already available at my hospital.
  13. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner

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    After reading the comments, and trying to look up what happened, I have more questions.
    I looked up the case on the Volusia County website and it doesn't give any extra information unfortunately. She sued pretty much everyone involved. In 2007 there was a paternity case, and later in 2009 there was a guardianship case.
    The nagging questions are few. While it is tough to fault EVAC, why wasn't a dedicated neonatal transport used? I mean, the reason for the transfer was preterm labor. It wasn't just high-risk OB. Halifax wasn't at fault because they couldn't accept something they can't care for, which is the reason to transfer from fish. Arnold Palmer (now Winnie) has ground and air. However, they're 70 miles away, and perhaps weather prevented air, who knows (anyone here life in Orlando in 2003?). Even if the ground had left AP instantly, she would have delivered a breech, coding premie at Fish instead of in the back of a bus and then taken to Sanford (about halfway to Orlando).
    The true tort that is misplaced is towards Halifax and the OB there. A doctor that never saw a patient, and couldn't take care of her, correctly didn't accept her, and got sued and eventually settled. Now just answering the damn phone puts you at risk.

    Things not mentioned in the article. Was she multip/grand multip? What kind of prenatal care did she have? Any PMHx?
    Last edited: May 25, 2010
  14. n2b8me

    n2b8me

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    ;)
    Last edited: Aug 7, 2013
  15. Siggy

    Siggy

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    As someone who's been monitoring and participating in this discussion both on JEMS Connect and other EMS forums, I've obsevered something very, very interesting. I've seen very few prehospital providers support the transport. I've seen absolutely zero phyisicians say that the transfer was inappropriate.
  16. xaelia

    xaelia neenlet

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    "With respect to a pregnant woman who is having contractions, an emergency medical condition is one in which:
    • There is inadequate time for safe transfer to another hospital before delivery; or
    • Transfer may pose a threat to the health or safety of the woman or the unborn child."

    With the information given regarding contractions 4 minutes apart, nondilated cervix, and membranes, I don't know if it's totally obvious that there is inadequate time for safe transfer to another hospital before delivery. Likewise, it sure would be nice if that second bullet point had something written into it where the risks of transfer were less than the risks of staying put.

    Our OB service accepts patients in preterm labor all the time for tocolysis and steroids; I suppose it's just a matter of time until they have an equally sticky outcome?
  17. GeneralVeers

    GeneralVeers Globus Hystericus

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    If your hospital has no OB capability it is not an EMTALA violation. A woman can be in active labor for hours. Is it reasonable to keep her in an ED without the support of an OB or neonatologist?

    The doctor in this case was screwed no matter what he/she did.
  18. southerndoc

    southerndoc life is good Moderator Emeritus Lifetime Donor

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    Exactly.

    Sometimes I see patients in the ED who have bad outcomes by the time they present and I just think that could be my first lawsuit. There's always some lawyer just eager to get his/her 30-50% cut on the award.
  19. NinerNiner999

    NinerNiner999 Senior Member

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    This case sucks. I wonder, though, if a consent to transfer was signed by the patient, and if the consent stated premature delivery or neonatal disability as potential complications of the transfer. Further, can anyone provide insight as to whether these documents would support defense in court?

    At my shop, we dictate our notes, and I'm pretty sure that a well dictated note addressing each potential outcome, understanding by the patient, and re-exam of the patient prior to transfer would be defensible.
  20. GeneralVeers

    GeneralVeers Globus Hystericus

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    We are having this argument now as a group. One of our facilities (the only hospital in the area) lost OB coverage. The hospital was apparently going to launch an education campaign and put out new signs. So far no signs have appeared, and OB/GYN emergencies are showing up daily as patients have no clue that we've lost OB. It's only a matter of time until we get one of these cases. It feels like playing Russian Roulette.
  21. dmitrinyr

    dmitrinyr Senior Member

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    This case sucks and is an extremely frightening concept for any EM physician. When you deal with a situation in which an EP gets sued and has to settle when he/she realized and made the correct decision (which was in the best interest of the mother and baby) not to accept the OB transfer, that is scary. I agree that the "expert witness" who testified for the prosecution had to be real scum to say that the paramedics did not meet standard of care when they really could not deny transfer (at least I think they couldn't) and did the best that they could to deliver a difficult delivery and resuscitate a 25 week old premie.

    This is why I hate lawyers. They know perfectly well that they are screwing the hospitals and doctors, but don't care. They are complete scum that is trying to squeeze every last cent out of the pity for the family involved. In any other country, the doctors/nurses/EMS crew would be praised for their effort and care and the family would send them flowers/cards/thanks instead of sending them a subpoena. I have friends who are lawyers and they're not as scummy but they do try to sue doctors whenever they can, because they're lawyers and are all vampires.
  22. Stitch

    Stitch Jedi Ninja Wizard Moderator

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    Just curious: do you all in the adult world have exposure to or certification in neonatal resuscitation protocols? There's no reason you would (making this scenario suck even more), but they are quite different from PALS or ACLS. Is that a potential source of liability (what isn't a potential source for that matter?)?
  23. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner

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    NRP is part of our training. Not sure if it is a requirement everywhere, but it should be for EM, OB, and peds. Anyone around deliveries should be well versed in them.
    I do find it interesting that many EMS people blame EVAC for not refusing the transport.
    The doctor's malpractice already settled, so they're certainly covering him.
    We transfer people more than 60 miles all the time. Some of our transports are more than 5 hours. Recently, we had one that we weren't sure would make it, so our mobile ICU with NICU/warmer left our facility while transport was leaving the other. They met about halfway. Luckily, it turned out well, but I bet after this case they won't try it again.
    It's still mindboggling that the Halifax doctor settled.
  24. docB

    docB Chronically painful Administrator SDN Senior Moderator Lifetime Donor

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    They're also screwing the communities that depend on these services. This was a public ambulance service. They could close down over this resulting in delays for people when they have to wait on an ambulance from another town.

    I took NRP 5 years ago. We spend most of our time hoping it won't happen to us.
  25. csmmedic

    csmmedic

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    Our NICU ambulance, like most in the country, are not capable of transporting an adult. They are specially designed and the gurney is removed, with a wheeled isolette in its place. There is no room for a pregnant female patient, and the staff on board (neonatal RT and RN) are not trained to care for a women in labor. Not only that, but these ambulances are limited resources and may be much farther away from the hospital then a standard 911 rig. It may be several hours before the neonatal rig can pick up the nursing staff at the receiving hospital and respond to the sending hospital. If the paramedic 911 rig can get the patient to the specialty hospital quicker, and the sending hospital agrees to give a MD/RN rider, this is a preferred method, perhaps the only method in that particular geographic region. This lawsuit is baseless, the only thing I see that could have been done differently was the medic requesting a rider.
  26. Dwindlin

    Dwindlin SDN Gold Donor Gold Donor

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    This article raised some questions for me as a medic, namely what would you do as a doc if a medic refused a transfer? Personally I didn't even know this was an option honestly, it would never even cross my mind to out-right refuse to take a transfer on a docs order.

    Now, I have requested certain things done, better airway management or orders for drugs prior to leaving for example.
  27. Paseo Del Norte

    Paseo Del Norte

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    Depends on the state and company in my area of the world. For example, my employer has pretty strict protocols in-place regarding preggos. If patients fall outside of protocol we refuse and offer to call a specialty team.
  28. Ergog

    Ergog

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    I was just passing through-- but I have been in this situation.

    This was a little rural hospital I was staffing last year where the OB had fled due to the malpractice climate. The locals knew we had no OB. So a woman decided to drop in to the ER at 28 weeks with contractions 4 minutes apart, no OB care to date, and a previous history of placenta accretia necessating large volume blood transfusion at her last delivery. Gotta love it.

    I felt a head at one side and feet at the other on my Leopolds exam, so did a quick ultrasound which confirmed a transverse presentation. I had the nearest OB on the phone pretty much immediately, and he accepted her transfer. My hospital had an ambulance on site with a 30-year experienced paramedic, and it was a 40 minute ride by ground so she went by ground. Helicopters weren't flying because it was pretty windy and this was faster anyway. One of our nurses who had previously worked L&D went along.

    15 minutes out her water broke. At 30 minutes the paramedic delivered the baby bilateral footling breech after seeing a foot stick out. I talked to him later and he said he had to reach into the uterus to grab the other foot. They were only 10 minutes away from the receiving hospital so I sure would not have done this.

    I was notified the next day though that the receiving hospital was reporting us for an EMTALA violation for transfering an "unstable woman in labor who delivered in the ambulance." There was a big blow up over this at my hospital, directed primarily against me, as they basically blamed me. For what, sending a high-risk pregnancy in premature labor with an undeliverable presentation and 28-week gestation to a facility with an obstetrician and NICU by the fastest and only means possible?

    Turns out this woman's family had previously sued the hospital for a "slip and fall," and complained that the baby was "bruised" from the delivery. Thing is, the baby was actually fine, which is about all that saved all our asses. She probably wasn't able to find grounds to sue, although of course the family has the next 18 years in which to file a suit for their childs future ADHD and meth addiction, both of which I predict to be inevitable.

    I did also talk with the accepting OB later, and he talked to the administration at his hospital such that they backed off on the EMTALA reporting. I'm not an EMTALA lawyer but by no means is EMTALA designed to prevent a physician from transferring a patient that needs immediate life-saving services you can't provide. There is only so much "stabilization" you can do, and then they just need to go. There is an obligation for every ER physician to be able to provide a certain degree of services, such as a normal vaginal delivery, but this does not include doing an emergency c-section on a high risk patient with an even more high risk 28-week baby, with no facilities to adequately care for either, and that is what was called for here.

    Regarding this hospital though, I never worked there again. The fact that they would try to throw me under the bus, and put all the blame on me, was enough for me to decide that I would be working elsewhere.
  29. Flopotomist

    Flopotomist I love the Chicago USPS

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    I am not a lawyer - but my understanding is that a physician has to verify that a deviation from the standard of care occurs in order for a case to proceed. If this is the case, perhaps we as a community should shine a light on the physicians who sign off on cases like this. Clearly, the physician acted as any reasonable physician would have (albeit perhaps not perfectly as there may or may not have been other options), and the medic acted reasonably (albeit perhaps not perfectly, but it is certainly reasonable to accept a transfer if an Emergency Physician is telling you that a transfer is in the patient's best interest).
  30. DoctorMedic

    DoctorMedic

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    I have to agree. As a Paramedic who am I to question a more trained physician (unless they are blatantly screwing the pooch)? We were taught as part of the National Curriculum how to deliver an imminent full term delivery. But we were not taught how to deal with a 25 week preemie or when they would deliver. I was never taught how to measure dilation of the cervix or perform a pelvic exam. I fail to see how the medics should have known the labor was imminent at the time of transfer. For a situation outside of my scope as EMS I would have no choice but to defer to the ordering physician.
  31. Dwindlin

    Dwindlin SDN Gold Donor Gold Donor

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    :thumbup:
  32. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner

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    Nope. Some want to make that part of reform (and some states may have), but currently it isn't required.
  33. DoctorMedic

    DoctorMedic

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    Think I'm gonna just practice in a state that has those great protection laws for ED docs. I think Ohio is the latest to implement them. It's ridiculous because this was def a damned if you do damned if you don't situation.
  34. Meibomian SxN

    Meibomian SxN

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    The article says that they are appealing the decision. Good for them and I hope they win! :xf:
  35. willow18

    willow18

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    AAEM sorta tries to "shine the light" on that. Previous discussions on this topic:

    http://forums.studentdoctor.net/showthread.php?t=294345

    http://forums.studentdoctor.net/showthread.php?t=672623
  36. Socrates25

    Socrates25

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    Its a little more complicated than that. According to the written law in most states, a doctor has to violate a "standard of care" to be negligent. Most states include that exact language.

    However, its not enforced in an actual court of law. All you need is one expert witness giving his opinion as to what the "standard" of care is. Thats not a real standard. A standard is decided upon by a community or organizations of people, not one idiot's opinion. But all that is required to prove that a "standard" was broken is one hired gun whore's "expert" opinion.
  37. Socrates25

    Socrates25

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    This is exactly right. You guys need to do yourselves a huge favor -- its an eye opening experience. Go find a copy of the ATLA (Trial Lawyers Assocation) monthly journal. Look in the back in the ads section. 75% of the ads are from DOCTORS whoring themselves out as "expert" witnesses to these lawyer scum.

    Publish their names. We should put these vampire leeches in the light of day so we can all see their names and know who the liars and thieves are among us.

    FYI: Being an expert witness pays EXTREMELY well. Usually expert witnesses earn at least triple the income per hour compared to what they get for doing regular old clinical medicine.
  38. Dr.McNinja

    Dr.McNinja Nobel War Prize Winner

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    That and res ipsa loquitur will work in general.
  39. southerndoc

    southerndoc life is good Moderator Emeritus Lifetime Donor

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    My state (Georgia) doesn't recognize that. Emergency providers must provide grossly negligent care in order to be held liable.
  40. GeneralVeers

    GeneralVeers Globus Hystericus

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    I've been told that expert witness testimony in a civil trial can be $750/hour, and this is from members of my group who have done this (except they are for the defendant).

    I recently had to be an "expert witness" in a criminal matter, and the hourly rate was significantly less.
  41. xaelia

    xaelia neenlet

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    My dad does this, typically representing insurance companies against bogus workman's compensation claims. Frequently, he'll be scheduled for a deposition, and they'll cancel for a settlement - he still bills by the hour for time spent in preparation as well as for the clinic schedule hours he cleared for the deposition.

    It does pay well.
  42. Stitch

    Stitch Jedi Ninja Wizard Moderator

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    Our forensic guys (they mainly do child abuse testimony) told us that we could ask for a specific rate in the event you are called to be an expert witness. So if it's relatively bogus and you don't want to go, just tell them your rate is $4000 an hour. They will likely change their minds about how much they really need you. If they are willing to pay that then it's probably worth your time! I haven't tried this however.

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