Transport liability

[cyanide12345678]

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How does liability work if a patient that is transferred gets into a bad wreck in an ambulance or helicopter?

Is it the fault of the ambulance crew or the Buck still falls on the sending ER doctor?

 

[thegenius]

Why would the ER doctor be at fault here?

 

[cyanide12345678]

Why would the ER doctor be at fault here?

Ultimately the transferring doctor is responsible for making sure the patient gets to the next facility safely. No?

 

[valianteffort]

I would assume that every ER transfer form in the America has the waiver of liability for MVC on the way to receiving hospital. Then again, what do forms really protect us from.

I could see an ER doc being sued for an MVC during transfer, but I don't think it would be the physical trauma aspect that would get us. Maybe I was sending a cardiac patient with known CAD to another hospital for pneumonia. MVC happens with no physical injuries but the event's stress leads to a STEMI and cardiac arrest/death. Plaintiff Lawter: Well Dr. X , didn't you realize the patients heart was 'unstable' and couldn't handle the stress of an MVC?

What a fantastic field we are in.

 

[hoot504]

What's the point in even worrying about this?

Greater shot of getting maimed in my own car wreck on the way to shift.

 

[thegenius]

Ultimately the transferring doctor is responsible for making sure the patient gets to the next facility safely. No?

Within reason, yea. But if the ambulance driver gets into an accident, especially if it's his fault, why would someone say the ER doctor is at fault here.

EDIT: even if it's not his fault. This isn't even medical. There was no medical malpractice in this case.

 

[emergentmd]

There is alot more to worry about like if the coffee shop made my cappuccino correctly.

 

[EctopicFetus]

You know what happens not infrequently and is a risk i dont think we should be taking with our patients.. HEMS. It’s super cool and is on the advertisement of 90% of the trauma programs. benefits for most patients who fly is minimal to none..

They crash not infrequently. Does anyone know of a lawsuit vs an ED doc related to this? That will answer your question.

 

[NYEMMED]

Ultimately the transferring doctor is responsible for making sure the patient gets to the next facility safely. No?

Medically yes.
You are responsible for the patient being stable enough to safely transport.

Not responsible for a crash, that would fall on the EMS agency

 

[InternistDO]

I worked in EMS for years, I've been involved in several ambulance accidents and my service got in several every year (busy department).

I've never heard of a physician having any responsibility at all other than signing the transport form for IFTs. It really ends up being an insurance issue (no lawyer is going to sue some medics making $20/hour).

I agree with whoever said that HEMS is a unique combination of extraordinary dangerous with almost no benefit to patient care the vast majority of the time, but again I'm not aware of any medical malpractice liability ever stemming from the dozens of fatal (and also often unnecessary) HEMS crashes.

 

[NYEMMED]

I worked in EMS for years, I've been involved in several ambulance accidents and my service got in several every year (busy department).

I've never heard of a physician having any responsibility at all other than signing the transport form for IFTs. It really ends up being an insurance issue (no lawyer is going to sue some medics making $20/hour).

I agree with whoever said that HEMS is a unique combination of extraordinary dangerous with almost no benefit to patient care the vast majority of the time, but again I'm not aware of any medical malpractice liability ever stemming from the dozens of fatal (and also often unnecessary) HEMS crashes.

I guess HEMS depends how far you are from facilities.

One of our sites is 1 hour by ground from our tertiary center, helicopter can do it in 15-20mins. That’s probably safer for a critically injured or sick patient.

But for a 15-30 mins drive? Probably better/faster by ground, unless of course it’s rush hour and will take an hour to drive.

 

[InternistDO]

I guess HEMS depends how far you are from facilities.

One of our sites is 1 hour by ground from our tertiary center, helicopter can do it in 15-20mins. That’s probably safer for a critically injured or sick patient.

But for a 15-30 mins drive? Probably better/faster by ground, unless of course it’s rush hour and will take an hour to drive.

How many patients does 40 minutes really matter though? And it's not really 20 mins vs 60 mins, since once you call dispatch/transfer center, speak to the accepting physician, get something dispatched, get an EMS unit to the ED, the patient transferred, etc you're more talking about 2 hours vs 2 hours and 40 minutes.

We're also not talking about unstabilized pre-hospital patients--there's only a small subset of patients that after ED stabilization are sick enough that they need tertiary care quickly enough that minutes matter but aren't so sick that they wouldn't survive the transfer.

The main problem is that the IFT and HEMS organizations are often staffed in a way where a critical care ambulance takes much much longer to get than a helicopter, so people are incentivized to fly borderline patients.

 

[JacobMcCandles]

If you recommended the transfer and then you drive/flew the patient yourself then I could see some issues. Otherwise, this shouldn’t even be something to even think about.

 

[cyanide12345678]

How many patients does 40 minutes really matter though? And it's not really 20 mins vs 60 mins, since once you call dispatch/transfer center, speak to the accepting physician, get something dispatched, get an EMS unit to the ED, the patient transferred, etc you're more talking about 2 hours vs 2 hours and 40 minutes.

We're also not talking about unstabilized pre-hospital patients--there's only a small subset of patients that after ED stabilization are sick enough that they need tertiary care quickly enough that minutes matter but aren't so sick that they wouldn't survive the transfer.

The main problem is that the IFT and HEMS organizations are often staffed in a way where a critical care ambulance takes much much longer to get than a helicopter, so people are incentivized to fly borderline patients.

At one of my critical care facilities, the ambulance transportation times were terrible - an average of 6 hour wait time for an ambulance to arrive.

So yeah I’ve been guilty of flying patients who technically could have gone by an ambulance - but i didn’t feel like they should be in a rural ER for 6-12 more hours.

 

[JacobMcCandles]

At one of my critical care facilities, the ambulance transportation times were terrible - an average of 6 hour wait time for an ambulance to arrive.

So yeah I’ve been guilty of flying patients who technically could have gone by an ambulance - but i didn’t feel like they should be in a rural ER for 6-12 more hours.

Maybe, maybe not. I also don't think they should be getting a $20k helicopter bill unless it's absolutely necessary.

 

[InternistDO]

At one of my critical care facilities, the ambulance transportation times were terrible - an average of 6 hour wait time for an ambulance to arrive.

So yeah I’ve been guilty of flying patients who technically could have gone by an ambulance - but i didn’t feel like they should be in a rural ER for 6-12 more hours.

Yeah that's basically what I was saying, you basically get forced into it. "Well if you say they need to fly we can be there in 30 minutes, but the ambulance will be 4-6 hours..."

And why wouldn't they? Ground EMS transport barely reimburses and you still have to pay for staffing either way. But it's still a very flawed system.

 

[cyanide12345678]

Maybe, maybe not. I also don't think they should be getting a $20k helicopter bill unless it's absolutely necessary.

Our system doesnt balance bill. Same cost of a critical care truck vs a critical care helicopter. Have had this conversation with them multiple times.

 

[thegenius]

At one of my critical care facilities, the ambulance transportation times were terrible - an average of 6 hour wait time for an ambulance to arrive.

So yeah I’ve been guilty of flying patients who technically could have gone by an ambulance - but i didn’t feel like they should be in a rural ER for 6-12 more hours

Real problem occurs when you have a twisted testicle and you only have a few hours before it dies. And transport averages 6 hrs. Ooph

 

[RuralEDDoc]

No, you aren’t liable for EMS crashes.
Yes, you can be sued for anything. But these kind of lawsuits don’t have legs. Dimissed predeposition. Not worth worrying about.

 

[emergentmd]

If docs get sued for initiating transport, then we have more things to worry about.

 

[Tenk]

While helicopter crashes are real and kill people, unless the ambulance is getting hit by a train I doubt anything would happen to the patient. Those things are basically tanks and the patient is usually in the middle of the ambulance strapped down and locked to the floor.

 

[southerndoc]

While helicopter crashes are real and kill people, unless the ambulance is getting hit by a train I doubt anything would happen to the patient. Those things are basically tanks and the patient is usually in the middle of the ambulance strapped down and locked to the floor.

Most ambulance crashes kill innocent civilians and not patients/paramedics. (Not saying they don't kill patients/paramedics, but the majority of fatalities are innocent bystanders.)

 

[Tenk]

Most ambulance crashes kill innocent civilians and not patients/paramedics. (Not saying they don't kill patients/paramedics, but the majority of fatalities are innocent bystanders.)

Yes, and most state laws actually protect EMS and police/emergent transport to the point of almost never being at fault. Another reason to get tf out of the way when you see one.

 

[Siggy]

Interestingly enough... the free Expert Witness substack case for this month is a transport case.

Confidential settlement, 18 month old transported to big city children's hospital, but decompensated in route and arrived peri-arrest. The person who runs the newsletter doesn't have kind words for the plaintiff's expert.

Pediatric Cardiac Arrest [Decompensation During Transfer]

Case #203

expertwitness.substack.com

 

[RuralEDDoc]

I may or may not have had a patient that ended with a…

Delete your post
Don’t make anything public
Accept that you are not liable and move on

 

[EctopicFetus]

How many patients does 40 minutes really matter though? And it's not really 20 mins vs 60 mins, since once you call dispatch/transfer center, speak to the accepting physician, get something dispatched, get an EMS unit to the ED, the patient transferred, etc you're more talking about 2 hours vs 2 hours and 40 minutes.

We're also not talking about unstabilized pre-hospital patients--there's only a small subset of patients that after ED stabilization are sick enough that they need tertiary care quickly enough that minutes matter but aren't so sick that they wouldn't survive the transfer.

The main problem is that the IFT and HEMS organizations are often staffed in a way where a critical care ambulance takes much much longer to get than a helicopter, so people are incentivized to fly borderline patients.

The incentive is the $$. 40-120k “cool” heli ride vs 2-3k ambulance. Also the data shows no benefit. NONE.. waste of money. I would argue if you are HOURS away then maybe. I have flown 2 patients in my near 20 year career. The first was a DKAer when i was moonlighting at a rural place and was pushed to do so by the hospitalist and I didnt have the knowledge or experience to say nah man thats dumb.

The 2nd was an aorta about to pop and the patient went from the helipad to the OR and died anyhow. I still think this was the right move for that one patient. IN my near 20 years im nearing probably 60-80k patients? Dont let their flyers and the RNs wanting to do flight push you to do something that wastes money, resources and pads the wallets of others for no benefit to your patients.

 

[gro2001]

I think all of you routinely encounter patients in whom a few minutes makes a difference.

A dominant hemisphere M1 occlusion loses about a week of life expectancy per minute that recannalization is delayed.

https://www.ahajournals.org/doi/10.1161/STROKEAHA.119.026735

Although there is not similar data for SAH patients (would be impossible to study), but anecdotally for high grade SAH with hydrocephalus minutes to EVD placement very much matter.

Agree the choice of what's faster is very dependent on local conditions and even the particular day's conditions (weather, traffic).

 

[InternistDO]

I think all of you routinely encounter patients in whom a few minutes makes a difference.

A dominant hemisphere M1 occlusion loses about a week of life expectancy per minute that recannalization is delayed.

https://www.ahajournals.org/doi/10.1161/STROKEAHA.119.026735

Although there is not similar data for SAH patients (would be impossible to study), but anecdotally for high grade SAH with hydrocephalus minutes to EVD placement very much matter.

Agree the choice of what's faster is very dependent on local conditions and even the particular day's conditions (weather, traffic).

I'm not arguing that minutes matter for some patients, it's just that for the vast majority of HEMS flights they don't, and for those that do the majority of "transfer time" is not time spent in the ambulance/helicopter, it's spent wrangling a bed and then waiting on EMS to show up in the first place, plus time at the receiving hospital getting them to the procedure bay (for the M1 example).

If you're at a rural CAH 2 hours by ground from the closest tertiary center, HEMS is a lifesaver. But if you're in (perhaps speaking from experience...) the suburbs surrounding Philadelphia you're saving maybe 30 minutes in transport time at best, and yet there are something like 10 HEMS units serving the area. And a large amount of those transports could potentially be avoided with better 911 EMS triage (like bypassing an 80 bed "stroke center" to proceed to a larger hospital 15 minutes further away with procedural stroke services).

I'm not in EMS any more, and obvious by my username not in EM, but how many high grade SAH patients who present to a facility incapable of placing an EVD are going to have a transfer time where they have a good outcome?

 

[wareagle726]

I may be the outlier but I routinely use HEMS for kids. Closest peds facility is 1.45-2hrs by ground. I have no peds and no peds hi-flow/bipapa/picu anywhere near. I routinely have to call the children's center for their crew to come and its always by helo because they get so many calls and it's just more efficient for the crew. And state medicare covers it. Also, I don't feel comfortable sending some of these kids with our crews.

On the other hand the last time I flew an adult was a dissection that had to go 300 miles away due to boarding but no I don't routinely fly adults.

I guess If I got sued for an ambulance crashing that is so far down the line of what I'm worried about I would chalk it up to "that's why I have insurance" and lose no sleep because it is literally just a money grab and in my soul I know it's not my fault.

 

[ERMudPhud]

Quite a few years ago we had a patient being transferred to a psych facility from our ER. They undid the buckles on the pram and opened the back door of the ambulance and jumped out on the highway and were run over. Everyone including the sending physician got sued. He got dropped from the suit fairly quickly. I think the private EMS agency had some changes to their protocols after that.

I work part-time in an urban setting. I almost never fly anyone there. LVO during rush hour might be the only exception. By the time you call the helicopter, they spin it up and fly over, spin it down, spend forever loading the patient, spin it back up, fly to the next hospital and unload you could have loaded them in a wheelbarrow and run them to the receiving hospital. I did once receive a heli that had flown 1 mile from a hospital whose cath lab was down. I suspect the patient could have walked over with their crushing chest pain faster

The rest of the time I'm in a mountain hospital. Minimum ground transport to tertiary care is 110 miles on a twisty mountain road. Pediatric tertiary care is 160 miles. We have a heli stationed at our hospital. I fly a lot. Almost everyone in town buys a medivac policy that covers out of pockets costs for something like $250/year. I haven't confirmed it but supposedly you can buy the policy 10 minutes before you get loaded into the heli. The real problem comes when the weather is terrible. Heli don't fly. Mountain road nearly impassable.

 

[gro2001]

I'm not arguing that minutes matter for some patients, it's just that for the vast majority of HEMS flights they don't, and for those that do the majority of "transfer time" is not time spent in the ambulance/helicopter, it's spent wrangling a bed and then waiting on EMS to show up in the first place, plus time at the receiving hospital getting them to the procedure bay (for the M1 example).

If you're at a rural CAH 2 hours by ground from the closest tertiary center, HEMS is a lifesaver. But if you're in (perhaps speaking from experience...) the suburbs surrounding Philadelphia you're saving maybe 30 minutes in transport time at best, and yet there are something like 10 HEMS units serving the area. And a large amount of those transports could potentially be avoided with better 911 EMS triage (like bypassing an 80 bed "stroke center" to proceed to a larger hospital 15 minutes further away with procedural stroke services).

I'm not in EMS any more, and obvious by my username not in EM, but how many high grade SAH patients who present to a facility incapable of placing an EVD are going to have a transfer time where they have a good outcome?

And conversely I am not arguing that the majority of HEMS flights are high yield (or at all helpful really). And while some of it is geographic (it will never make sense to fly someone in NYC, it will often make sense to fly someone in Alaska) another big component is the quality of the transfer system. And also agree that a bigger impact is optimizing the upstream EMS process on a system level. But there is a lot of potential benefit in optimizing interfaculty transfers so that the biggest time component is actual transport time.

I've worked in a health system where we really honed our neuroemergency transfers. I could activate a life rescue transfer that would be picked up from the sending hospital within 20 minutes of me saying go (>90% of the time). So I would receive a phone call from one of our sending hospitals via the transfer center and as soon as I heard enough that convinced me the patient needed to come here ASAP I would say "please activate life rescue" and while I am still getting the rest of the clinical details from the sending doc, the transfer center would work on dispatching an ambulance. They could get such short times by contracting with various EMS agencies all around the hospitals we typically receive transfers from. So not infrequently the picking up ambulance would literally be right outside the sending facility anyway. Our ER and neuroICU were all in sync on this, so no matter what we'd always have a bed ready for them to land. The neurosurgery fellow would be in the room, sometimes already gowned with an open EVD kit.

We even started doing 23.4% hypertonic saline via direct femoral stick (so ultrasound guided injection into femoral vein, just as would with a central line except I am not leaving a catheter in; so satisfied the hospital admins that I am not breaking any central line protocols re sterility/consent etc as there is no line, and I am not breaking any policies about administration of 23.4% because it is administered into a central vein). I am not saying this is specifically a practice everyone should adopt (since then there has been a fair amount of literature about safe administration of 23.4 via peripheral line) but this is to show that in a system that is mission committed to shaving minutes of neuroemergency transfers there are lots of opportunities. A system with such a level of commitment to making this process work that is located in a more sparsely populated area with rougher terrain could make a HEMS system work beautifully.