More Liability For EPs

[docB]

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I’m getting asked more and more to write specific notes clearing people to go back to work or to fly on passenger planes. This is a new area of liability. Writing someone to be off work is one thing but me specifically saying they’re cleared by me to go back to work is different. The flying thing really scares me.

If I say someone is clear to go back to work and they have some problem, related to their original complaint or not, and they injure themselves or someone else, I’m on the hook for those injuries. I don’t really know what the criteria for being clear to go back to work as an armed security guard or a crane operator are.

The flying thing is even worse. I get a lot of this being in Vegas. The airline refuses to board someone because they’re sick. They send them to the ED and tell them they have to get a letter from the doctor telling them that they’re cleared to fly. If I don’t give them this letter they will be trapped here. If I do give them this “clearance” and the airline has to divert a flight because the person has a problem in flight then I’m liable for all the costs the airline incurs from the flight diversion. If a passenger jet diverts to a different city for a medical emergency the cost to me will be in the $50-100K range.

I’ve tried writing vague “clear for all regular activities” notes but the employers and the airlines are now sending these patients back to the ED for specific letters. The hospitals are demanding that we write them because the patients complain if we don’t. It sucks being a contract doc.

Anybody else seeing this troubling trend?

 

[Annette]

If the hospital wants you to write these letters, maybe their lawyers should draft them. After all, the hospital has deeper pockets than you.

 

[bulgethetwine]

If the hospital wants you to write these letters, maybe their lawyers should draft them. After all, the hospital has deeper pockets than you.

The work issue is easy -- I invariably refer them to risk management. The issue of air travel is different since, if I refer them to risk mgmt, they're stuck in the city until.

Yup, it's bull****.

 

[Wackie]

Well, technically your job is to rule out emergent conditions, right? So can you basically pass the buck to their PCP, ortho, or whatever specialty they should be following up with and explain to the patient that doctor is the one who can clear them?

 

[elwademd]

I’m getting asked more and more to write specific notes clearing people to go back to work or to fly on passenger planes. This is a new area of liability. Writing someone to be off work is one thing but me specifically saying they’re cleared by me to go back to work is different. The flying thing really scares me.

If I say someone is clear to go back to work and they have some problem, related to their original complaint or not, and they injure themselves or someone else, I’m on the hook for those injuries. I don’t really know what the criteria for being clear to go back to work as an armed security guard or a crane operator are.

The flying thing is even worse. I get a lot of this being in Vegas. The airline refuses to board someone because they’re sick. They send them to the ED and tell them they have to get a letter from the doctor telling them that they’re cleared to fly. If I don’t give them this letter they will be trapped here. If I do give them this “clearance” and the airline has to divert a flight because the person has a problem in flight then I’m liable for all the costs the airline incurs from the flight diversion. If a passenger jet diverts to a different city for a medical emergency the cost to me will be in the $50-100K range.

I’ve tried writing vague “clear for all regular activities” notes but the employers and the airlines are now sending these patients back to the ED for specific letters. The hospitals are demanding that we write them because the patients complain if we don’t. It sucks being a contract doc.

Anybody else seeing this troubling trend?

employers sending employees to the ed should be a no-no. they should be referring these patients to their contracted workman's compensation clinic. it's the doc in the workman's comp clinic that has the understanding of the different things that the employers are looking for (for example, a driver for ups should have a different set of regulations/things he/she needs to do as opposed to say the guy/gal who flips burgers at the local burger joint).

add to that, if it is a work related injury, the patient should alwasy be told to go to his/her human resources department in order to find out where the workman's comp clinic is.

i'm not sure about the patient who happens to be traveling issue. i assume that any sort of crucial diagnosis such as an m.i. or p.e. would be admitted! so, perhaps airlines are a bit more scared these days of someone having tb or sars... as opposed to say, the common cold????!!!?????

i suppose that as long as you have the documentation that at the time you saw the patient, there was no emergent condition preventing the patient from traveling that you should be ok.

 

[Flopotomist]

I am curious about the billing issue for this. If this patient presents to the ED for this non-emergent complaint (I need paperwork done is not an emergency) can't you just do a cursory exam to comply with EMTALA and then refuse to do the paperwork unless the patient has paid the $2,500 ED bill up front?

This would deter most patients, but in the event that you had to fill out the paperwork would at least help balance the risk/benefit scales in your favor.

 

[Hayduke]

The flying thing is even worse. I get a lot of this being in Vegas. The airline refuses to board someone because they're sick. They send them to the ED and tell them they have to get a letter from the doctor telling them that they're cleared to fly.

As you already know, this is an abuse of the ED. You are not being utilized to treat an emergent condition. You are not a flight physician. You are not boarded in occ.health (as far as I know) You are being hung with this liability because you are AVAILABLE.

Your contract and EMTALA keeps you vulnerable. Recognizing that you only have so many trips to the request bucket for the hospital, is it possible for your group to enlist the help of the risk mgt. folks at the facility? Given your location, it seems like this could become a routine "free" benefit to airlines with no actual income generated for the hospital. The doc is stuck assuming a large amount of risk.

If this is becoming a common occurrence (weekly?) eventually somebody is going to go with the fish instead of the chicken....Then momma's gonna have to learn how to speak jive.

 

[Hayduke]

On a random tangent-
I worked with an EM boarded guy that had picked up some kind of occupational health certificate. He had an officeless business where he would drive to different industrial work sites and provide physicals including PFTs.
Painful, boring, minimal risk, but $$$$.

This also allowed him to bill for the stuff about which docB is complaining.
The little he shared with me about occ. health risk is not so much your clinical accumen, but how well you could read an actuarial table. Industry has more robust data about accidents than anything coming out of the ACC. It's the real EBM.

 

[Febrifuge]

eventually somebody is going to go with the fish instead of the chicken....Then momma's gonna have to learn how to speak jive.

Well played, sir.

 

[Winged Scapula]

Unfortunately, its a fairly common problem in vacation destinations like Vegas.

My ex is a surgeon there and often gets asked for the same type of notes that docB does. Reasonable because he's the person who operated on them but the airlines are wanting him to clear the patient of any possible problems...how can he/you/the next guy do that? Its one thing to say, like docB points out that a patient is safe to return to work or perhaps even to fly, but as I understand it the airlines want these letters as some sort of protection in case the guy has an unrelated medical problem during the flight.

I have no problem looking at the patient's wound and overall medical condition and stating that they appear to be safe for airline travel, but we all know people who have post-op/post-hospitalization events which may not be related to the primary condition. Are we supposed to have a crystal ball?😡

While I understand the concerns of the ED crew about patients using the ED inappropriately this way, what are they to do when they are on vacation? Its unlikely they'll get a letter from their PCP hundreds or thousands of miles away. The idea of having Risk Management writing the letter sounds appealing but I'm not sure its realistic.

 

[FoughtFyr]

Hey DocB,

Why not write a letter laden with qualifiers?

i.e.,

To Whom It May Concern:

I have examined {insert patient name} in the emergency department on {insert date} and have been asked to provide them clearance to {fly commercially or return to work} after their having suffered {insert condition}. I {was or was not} the physician who provided definitive care for this condition. My examination today does not reveal any reason that {patient's name} can not {fly commercially or return to work}, however, my exam is limited by the resources available in the emergency department. While my exam today does not reveal any specific concerns, there remains a chance that the patient could suffer a relapse of their condition or suffer a new injury or illness if they {fly commercially or return to work}. This relapse or new condition might require emergency care or result in significant disability or death. It is impossible to determine if {insert patient name} is at significantly greater risk than other individuals to suffer an emergency condition. Please check with your company's risk management team to determine how to proceed.

Sincerely,

DocB​

Would that work? I mean you are saying that you have examined them, found nothing, but can not be responsible for anything that goes on...

- H

 

[GeneralVeers]

I'm going to cut and paste that letter, and save it for future use next time I'm asked to "clear" somebody. That's some nice work there.

 

[Dr.Evil1]

I am curious as to what conditions the airlines send people to the ED to get checked out? How are the airlines even aware that the person is not completely healthy?

Sounds like this is the perfect topic for your group to have a policy on. If you have an issue with it then I would think that others do too. I would guess that some outside consultation would be needed. Let us all know how things go.

 

[southerndoc]

I'm going to cut and paste that letter, and save it for future use next time I'm asked to "clear" somebody. That's some nice work there.

Make sure you clear it with a lawyer or your hospital's legal department.

When I rebooked my Dad's AirTran flight and specifically told him he couldn't fly for a week because of his surgery, they rebooked his flight (free of charge) and never asked for anything stating it was ok to fly.

 

[canjosh]

I am curious as to what conditions the airlines send people to the ED to get checked out? How are the airlines even aware that the person is not completely healthy?

Sounds like this is the perfect topic for your group to have a policy on. If you have an issue with it then I would think that others do too. I would guess that some outside consultation would be needed. Let us all know how things go.

Usually, they've gotten ill/injured on a flight, and the airline is requesting a letter for a continuance/return flight. I work in a hospital that is in the shadow of a busy international airport, and we see this stuff often. Usually, the docs have no problem signing the 'allowed to fly' letter. If they have a condition which precludes them from flying it is usually apparent in the ED and/or it's an obvious admission (DVT, PE, MI, etc.).
I've never heard about an airline coming after a physician for diversionary costs...I'm not saying it hasn't happened, I've just never heard of that becoming an issue.

 

[Old_Mil]

Here's a link to the FAA's minimum requirements/disqualifying conditions to get a first class medical certificate:

http://www.leftseat.com/far67.htm#14:2.0.1.1.5.2

It's my guess that if a potential passenger met these standards, they'll be pretty safe to put on an airplane...given that if they met these standards and happened to hold a pilot's license, the FAA would consider them medically qualified to fly that airplane.

If anything ever came up, you could argue that you'd made sure the passenger in question met the same standard as the guy driving at the time you saw him.

Good luck (and my medical advice is free, but comes with no guarantees).

 

[Annette]

If the hospital wants the ED to write these notes, then the hospital should be taking the liability as well. Let risk management compose the letters (or run foughtfyr's past them).

 

[docB]

Well, technically your job is to rule out emergent conditions, right? So can you basically pass the buck to their PCP, ortho, or whatever specialty they should be following up with and explain to the patient that doctor is the one who can clear them?

I've been out of town for a week so I'm behind on my SDN. Thanks for all the responses. Here's a blast of replies:

These people can't be sent to a PCP because they're traveling and don't have one here. They need the letter to get home otherwise they are "trapped" here. For some reason they all get mad at me and say I'm the one trapping them not the airlines who are the real culprits.

 

[docB]

employers sending employees to the ed should be a no-no. they should be referring these patients to their contracted workman's compensation clinic. it's the doc in the workman's comp clinic that has the understanding of the different things that the employers are looking for (for example, a driver for ups should have a different set of regulations/things he/she needs to do as opposed to say the guy/gal who flips burgers at the local burger joint).

add to that, if it is a work related injury, the patient should alwasy be told to go to his/her human resources department in order to find out where the workman's comp clinic is.

i'm not sure about the patient who happens to be traveling issue. i assume that any sort of crucial diagnosis such as an m.i. or p.e. would be admitted! so, perhaps airlines are a bit more scared these days of someone having tb or sars... as opposed to say, the common cold????!!!?????

i suppose that as long as you have the documentation that at the time you saw the patient, there was no emergent condition preventing the patient from traveling that you should be ok.

They are coming for emergent conditions but many don't require admission. Here's a good example:

30 F with asthma comes in with exacerbation. Airline refused to let her on board because she was having lots of SOB/wheezing. Now that the airline knows she's got a problem they will demand a clearance letter to let her board any future flight. I treat her in the ED and she improves and doesn't need admission. So, what do we all do with these patients? We send them home and tell them to come back if they get worse. If they start to wheeze again they come back. Usually not a big deal. But with this clearence letter they now go get on a plane. In flight they start to wheeze again and they can't just come back to the ED. Now the flight gets diverted to a different city. Who's on the hook for the cost of all that? Well, who signed the letter saying she could fly?

 

[docB]

Hey DocB,

Why not write a letter laden with qualifiers?

i.e.,

To Whom It May Concern:

I have examined {insert patient name} in the emergency department on {insert date} and have been asked to provide them clearance to {fly commercially or return to work} after their having suffered {insert condition}. I {was or was not} the physician who provided definitive care for this condition. My examination today does not reveal any reason that {patient's name} can not {fly commercially or return to work}, however, my exam is limited by the resources available in the emergency department. While my exam today does not reveal any specific concerns, there remains a chance that the patient could suffer a relapse of their condition or suffer a new injury or illness if they {fly commercially or return to work}. This relapse or new condition might require emergency care or result in significant disability or death. It is impossible to determine if {insert patient name} is at significantly greater risk than other individuals to suffer an emergency condition. Please check with your company's risk management team to determine how to proceed.

Sincerely,

DocB​

Would that work? I mean you are saying that you have examined them, found nothing, but can not be responsible for anything that goes on...

- H

This is a great idea. I've been thinking of something similar. Problem is I'll have to run it through risk mgmt. and then the Med Exec forms comittee. Ugh. It's still probably the best solution.

 

[docB]

I am curious as to what conditions the airlines send people to the ED to get checked out? How are the airlines even aware that the person is not completely healthy?

Sounds like this is the perfect topic for your group to have a policy on. If you have an issue with it then I would think that others do too. I would guess that some outside consultation would be needed. Let us all know how things go.

Some recent examples where a person came to the ED and was treated, discharged and needed the letter include: seizure, asthma, bronchitis, syncope, abdominal pain, gastroenteritis and neuropathy.

 

[ERMudPhud]

Back in the day I was doing an EMS rotation and spent a day with paramedics at the local international airport. We went on a call to one of the check-in lines for a patient having a "heart attack" We arrived to find a very angry flier who apparently felt he had been screwed by the airline in some ways. He had worked himself up screaming at the check in lady to the point that he was actually red faced, diaphoretic, and somewhat short of breath; not from an MI but from screaming.

A shortened version of the dialogue went something like this:

Paramedic: "Sir, are you sure you are ok you look to me like you might be having a heart attack"

Passenger: "I'm not having a heart attack I'm pissed 'cause their screwing me out of an aisle seat and this B**** is going to pay"

Attendent: "Sir, I'm sorry but if in their expert medical opinion you might be having a heart attack then I can't allow you to fly until you've been cleared by a physician"

The whole process took much longer but eventually the passenger caved to the inevitable and headed off to the hospital to get cleared to fly. It was clear to me from watching the whole charade that the medics and the check-in lady had been through this whole scripted routine more than once before.

 

[docB]

Back in the day I was doing an EMS rotation and spent a day with paramedics at the local international airport. We went on a call to one of the check-in lines for a patient having a "heart attack" We arrived to find a very angry flier who apparently felt he had been screwed by the airline in some ways. He had worked himself up screaming at the check in lady to the point that he was actually red faced, diaphoretic, and somewhat short of breath; not from an MI but from screaming.

A shortened version of the dialogue went something like this:

Paramedic: "Sir, are you sure you are ok you look to me like you might be having a heart attack"

Passenger: "I'm not having a heart attack I'm pissed 'cause their screwing me out of an aisle seat and this B**** is going to pay"

Attendent: "Sir, I'm sorry but if in their expert medical opinion you might be having a heart attack then I can't allow you to fly until you've been cleared by a physician"

The whole process took much longer but eventually the passenger caved to the inevitable and headed off to the hospital to get cleared to fly. It was clear to me from watching the whole charade that the medics and the check-in lady had been through this whole scripted routine more than once before.

I'm always wound up. This just gives me focus.😉

My concern about these things is that it seems like anyone (airlines, employers, schools, etc.) can tell their respective people to make sure they get these "clearences" from us at the conclusion of their ED visits. I don't want to bear the liability for clearing someone to fly or clearing someone to go back to work. I'm fine discharging someone with the blanket "go and do what you want, it's on you" instructions. When I start giving them documentation that I certify they are safe to do a specific thing like drive a bus, fly, carry a gun, whatever, then I'm liable if they screw it up. I can't practice with that kind of extra liability. I don't even know if my med mal insurance would cover me if this goes bad.

 

[RockfordWF]

I’m getting asked more and more to write specific notes clearing people to go back to work or to fly on passenger planes. This is a new area of liability. Writing someone to be off work is one thing but me specifically saying they’re cleared by me to go back to work is different. The flying thing really scares me.

If I say someone is clear to go back to work and they have some problem, related to their original complaint or not, and they injure themselves or someone else, I’m on the hook for those injuries. I don’t really know what the criteria for being clear to go back to work as an armed security guard or a crane operator are.

The flying thing is even worse. I get a lot of this being in Vegas. The airline refuses to board someone because they’re sick. They send them to the ED and tell them they have to get a letter from the doctor telling them that they’re cleared to fly. If I don’t give them this letter they will be trapped here. If I do give them this “clearance” and the airline has to divert a flight because the person has a problem in flight then I’m liable for all the costs the airline incurs from the flight diversion. If a passenger jet diverts to a different city for a medical emergency the cost to me will be in the $50-100K range.

I’ve tried writing vague “clear for all regular activities” notes but the employers and the airlines are now sending these patients back to the ED for specific letters. The hospitals are demanding that we write them because the patients complain if we don’t. It sucks being a contract doc.

Anybody else seeing this troubling trend?

I was under the impression that you always have the patient follow up with their PCP, and then at that time receive clearance. I'm not sure how the hospital or patient can argue with that. This is what I would do.

 

[Hawkeye Kid]

I was under the impression that you always have the patient follow up with their PCP, and then at that time receive clearance. I'm not sure how the hospital or patient can argue with that. This is what I would do.

the problem in this case (to save docB from restating it--again) is that the person needs clearance to get on the plane before they could even think about seeing their PCP. If you're in Vegas but from Chicago, then presumably your PCP is in Chicago as well. Following up with them in a week is fine and dandy, assuming you can physically get to them. These people aren't allowed to do this without a written blessing from someone with the proper initials and therein lies the problem of a potential liability disaster.

 

[docB]

the problem in this case (to save docB from restating it--again) is that the person needs clearance to get on the plane before they could even think about seeing their PCP. If you're in Vegas but from Chicago, then presumably your PCP is in Chicago as well. Following up with them in a week is fine and dandy, assuming you can physically get to them. These people aren't allowed to do this without a written blessing from someone with the proper initials and therein lies the problem of a potential liability disaster.

Well said and thank you. I will add that once you're in private practice you'd be amazed what hospitals will ask you to do.