EMTALA, C Section, and Hospitals with no Ob

[theWUbear]

---

Members do not see this ad.

Doing mandatory EMTALA training for onboarding. Yawn. This stood out to me:

Hospitals are obligated to provide any service that may be required, including anesthesia, cesarean section, and intensive care for the mother or newborn as necessary until any EMC is stabilized (note: true contractions are an EMC)

If you work at a hospital without Ob and a patient comes in in early labor, say, at 36 weeks, stating she is scheduled for C section the next day (at the hospital across town, that has Ob on call) for history of multiple C sections and concern for uterine rupture, what do you, the ER provider, do?

 

[Apollyon]

Yikes, seriously, what do you do? (Remembering the late, great, Dennis Hopper, in Speed.)

I mean, the OBs can do a vertical slash, and have the kid out in 90 seconds. But, we ain't OBs!

Your post scares me, because, just like @Rekt said in another thread, it's just a hot potato. It's musical chairs, with, when the music stops, who gets screwed?

I'm sorry that I do not have anything more creative to add.

 

[southerndoc]

Yes, that's exactly what you do.

In all seriousness, there is no right answer. You do not have the capacity to treat the patient at your facility based on lack of NICU and lack of OB. Ideally you would transfer the patient... if stable enough for transport. This is one of those situations where no matter what you do, you are exposed to liability.

 

[TheSingularity]

I would NEVER work at a hospital without in house OB. You're just freaking asking for it.

Seriously, any other specialty I can manage without:

No cards? TPA and transfer to cath
No ortho? Reduce / Splint as best you can and refer for next day

Most everything else is stabilize as best possible and transfer / close followup.

Not OB though. If something bad happens to that little peanut, your ass is grass. Plus you will feel horrible. It's literal negligence for a hospital not to have in house OB IMO.

 

[turkeyjerky]

This sounds like typical admin overreach and misinterpretation. EMTALA does not obligate you to "stabilize" a patient, if it's beyond your capacity to do so.

You don't need to fix a type A dissection before transfer.

I can't bring back a dead body. That doesn't mean that it's an EMTALA violation to discharge to the morgue.

Some relevant clauses from the law:

"the hospital must provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department to determine if an emergency medical condition exists"

If OB is not routinely available at your facility, a Csection is not within your facilities capability, and is thus not required prior to transfer.

"(B) with respect to a pregnant woman who is having contractions–
  (i) That there is inadequate time to effect a safe transfer to another hospital before delivery, or
  (ii) that transfer may pose a threat to the health or safety of the woman or the unborn child."

If she's crowning, you have to deliver the baby. But there's nothing in EMTALA about requiring an elective C-section prior to transfer.

(in the case mentioned by the OP, if your hospital did have OB I believe it could be construed as an EMTALA violation to transfer the patient to her previously scheduled hospital. But that would easily be rectified by having the patient sign on the dotted line saying she was requesting transfer. Because, after all, I doubt you'd be transferring her to a different shop w/o her consent.)

 

[turkeyjerky]

This is the same type of Admin BS as them saying it's a "HIPAA violation" to look at your own medical records.

 

[thegenius]

I agree with turkey jerky. Moreover I suspect that if an EMTALA violation was levied it would be against the hospital and not the ER doc.

ER doctors are not trained to perform C-Sections.

We would all transfer that woman ASAP.

And yell at her for not driving the extra 20 mins to get to the other hospital.

 

[Vandalia]

"No one is obligated to do the impossible."

If you are (at) a five bed, rural hospital that does not advertise OB services, and someone comes through the door, then you (the hospital) is only obligated to provide care that is within the scope of an EM physician/department.

Now, if you are a 200 bed hospital that advertises OB care, and a number of women are expecting to deliver at that facility, but no OB show up - either due to eating bad dip at the Christmas party or a contractual dispute - then there would be tremendous liability for the hospital. You will probably also be named in the suit, but it will not be an issue in the end.

If transfer is a practical option, it is simple. If it isn't, then things get complex. It raises the question of how you could/should handle "long shot" situations that are at the far outer edges of your training; i.e., OB, neurosurgery, etc. "Do no harm?", or "They are dead anyway, I can't make it any worse?"

It is something you will likely confront at some point in your career. You may have come up with your answer at 3 am on a quiet night in residency, or at an ethics Grand Rounds, but all that changes when it is real.

 

[HankTheTank910]

I agree with turkey jerky. Moreover I suspect that if an EMTALA violation was levied it would be against the hospital and not the ER doc.

ER doctors are not trained to perform C-Sections.

We would all transfer that woman ASAP.

And yell at her for not driving the extra 20 mins to get to the other hospital.

Similarly I recently had a mother bring in her congenital heart with pacemaker, trach/PEG, developmentally delayed non-verbal 9 year old child with respiratory distress and sepsis into my little 8 bed standalone ER when a Children's hospital was 15 minutes away.

Frustrating for sure. One of the quicker transfers I've had.

 

[Groove]

Check out this Indian doc doing a c-section. Doctor Greased lightning!

 

[GeneralVeers]

Similarly I recently had a mother bring in her congenital heart with pacemaker, trach/PEG, developmentally delayed non-verbal 9 year old child with respiratory distress and sepsis into my little 8 bed standalone ER when a Children's hospital was 15 minutes away.

Frustrating for sure. One of the quicker transfers I've had.

Exactly. It's always frustrating. Patients are under no obligation to perform basic due diligence to find a facility with some capability of caring for them. We take all of the liability for their lack of to do basic research. In your example that mother certainly should have known which place was appropriate to take her child with complex medical problems.

 

[WilcoWorld]

Check out this Indian doc doing a c-section. Doctor Greased lightning!

Not much blood loss either!

 

[AlmostAnMD]

If the head isn't out it's ready to ship

I am not obligated to wait until that thing crowns

 

[PTPoeny]

Exactly. It's always frustrating. Patients are under no obligation to perform basic due diligence to find a facility with some capability of caring for them. We take all of the liability for their lack of to do basic research. In your example that mother certainly should have known which place was appropriate to take her child with complex medical problems.

As PICU doc in a big children's hospital we actually spend a lot of time convincing families that they need to take their complex kids to the nearest ED for breathing problems. I have unfortunately taken care of multiple children who arrived moribund by private vehicle after family drove them past other EDs to the children's hospital while the kid wasn't breathing adequately.

I completely get why you would prefer these kids are in a dedicated peds hospital and I do too. However, 15 minutes isn't far unless that respiratory distress is actually respiratory failure and then it is very far.

 

[Lexdiamondz]

As PICU doc in a big children's hospital we actually spend a lot of time convincing families that they need to take their complex kids to the nearest ED for breathing problems. I have unfortunately taken care of multiple children who arrived moribund by private vehicle after family drove them past other EDs to the children's hospital while the kid wasn't breathing adequately.

I completely get why you would prefer these kids are in a dedicated peds hospital and I do too. However, 15 minutes isn't far unless that respiratory distress is actually respiratory failure and then it is very far.

The flipside is that many places are truly not equiped to take care of sick kids. I'm talking no peds ET tubes, mis-sized vent tubing, nurses unfamilar with PALS med doses, EDs staffed by IM docs who havent seen a kid since 3rd year med school type of BS.

 

[GeneralVeers]

The flipside is that many places are truly not equiped to take care of sick kids. I'm talking no peds ET tubes, mis-sized vent tubing, nurses unfamilar with PALS med doses, EDs staffed by IM docs who havent seen a kid since 3rd year med school type of BS.

Correct. It's a gamble taking a really sick, complex kid to a community (non-peds) hospital. Sure the ED physician could be knowledgable, and competent enough to stabilize, but there's also a chance that this could delay life-saving care. For respiratory problems shouldn't a parent just call EMS and have them take to the most appropriate facility?

 

[PTPoeny]

Correct. It's a gamble taking a really sick, complex kid to a community (non-peds) hospital. Sure the ED physician could be knowledgable, and competent enough to stabilize, but there's also a chance that this could delay life-saving care. For respiratory problems shouldn't a parent just call EMS and have them take to the most appropriate facility?

You are definitely correct I should have said the families need to let EMS take their kid wherever the local transport protocols dictate. Unfortunately some families refuse to call 911 or refuse transport to completely reasonably staffed EDs because it isn't where their specialists are located or they had a "bad experience" with a minor problem (like waiting too long).

I take transports from plenty of these poorly stocked/staffed EDs and going somewhere else isn't always an option. If the nearest more thoroughly stocked/ true EM staffed facility is an hour away and the very sick, complex kid is in true distress they are going to the poorly staffed/stocked place. Yes, it is a gamble to go to that ED, but it is a definite bad outcome if the family refuses transport and throws that not effectively breathing kid in the back of the personal car and drives an hour to the better stocked/staffed ED (or instead drives two hours and comes straight to the children's hospital). Some of these places EMS dispatch will reach out and my team is in the air before the kid even reaches the outside facility. It's a bad situation when they are hand bagging till we get there with the right sized equipment but it is better than a dead kid in the backseat of a car. I wasn't trying to start an argument just pointing out that there are times where it is appropriate for these kids to end up in community EDs.

 

[migm]

our RN + paramedic team will not transport from a no-speciality critical access hospital to the main hospital if the cervix is greater than 4cm. no idea what i'm supposed to do about that but leads to some pretty uncomfortable scenarios and underestimation of cervical maturity..

 

[namethatsmell]

Similarly I recently had a mother bring in her congenital heart with pacemaker, trach/PEG, developmentally delayed non-verbal 9 year old child with respiratory distress and sepsis into my little 8 bed standalone ER when a Children's hospital was 15 minutes away.

Frustrating for sure. One of the quicker transfers I've had.

Used to happen all the time at a small placed I worked at. The most common reason parents gave was "the children's hospital and all their specialists don't know what they're doing. When little Billy started to have trouble breathing a few hours ago we called them and they told us to come in immediately. Instead, we meditated on it for an hour and decided we're tired of going there and so we just fired all those doctors. But we brought you 1017 pages of records to read immediately so you can permanently fix our child."

There's a special place in one of Dante's circles for these folks.

 

[GeneralVeers]

our RN + paramedic team will not transport from a no-speciality critical access hospital to the main hospital if the cervix is greater than 4cm. no idea what i'm supposed to do about that but leads to some pretty uncomfortable scenarios and underestimation of cervical maturity..

We had the same rule at one of my hospitals that lost OB/GYN. Surprisingly every pregnant female I saw had a cervix less than 3 cm dilated.

 

[DrDrummer]

The flipside is that many places are truly not equiped to take care of sick kids. I'm talking no peds ET tubes, mis-sized vent tubing, nurses unfamilar with PALS med doses, EDs staffed by IM docs who havent seen a kid since 3rd year med school type of BS.

This is on those EDs and is leaving them open to fairly serious litigation in the case of a bad outcome. It is indefensible to fail to be ready for pediatric emergencies if you call yourself an emergency department, but unfortunately as you say many are in that exact state. The National Pediatric Readiness Project is something that aims to change that, but it really does need a local champion at every ER and unfortunately most don't have someone willing to take that on. As a new grad who works exclusively in single coverage EDs without pediatrics at any of them, I am obsessive about checking these things at the beginning of shifts and mentally rehearsing for this stuff because I fully anticipate the nurses not being ready for these cases. Knock on wood, I have yet to have the truly crashing neonate or congenital heart kid show up at one of my sites but I think about these scenarios frequently and whenever I find that we're missing the right equipment I'm writing e-mails and CCing leadership to get those things addressed ASAP.

For instance, next time you sedate a kiddo, ask the RT or RN to grab an appropriately sized LMA for the kid, just to have in case you need it. Watch how long it takes them to find it, if they even know what you're talking about. If it's longer than a minute, you need to address that at the level of department leadership.