Bernard Heilicser, D.O., M.S., FACEP, FACOEP-D

In this issue of The Pulse we will review the dilemma presented in the April 2018 issue, referred to us by a frustrated paramedic.

The situation involved a 70-year-old female patient being transferred from an urgent aid to an affiliated hospital emergency department. The patient had sustained a fall injury and struck her head.  She was on anticoagulant medication.

The EMS crew noted the patient to be “a little restless …complaining of a headache”.  Although, initially alert with normal vital signs, she became disoriented.  The paramedic asked the physician if he would consider transferring the patient to a Trauma Center, concerned for a possible intracranial bleed.  The physician told him to run it by the accepting ED for medical control.  Diversion was denied. En route, the patient became nonverbal and responsive only to pain.  Diversion was again denied. The same crew was later called to transfer the patient to a different trauma center that had an arrangement with the initial receiving hospital.  The diagnosis:  Intracranial Bleed.

What could the EMS crew have done to change this frustrating scenario?

What would you do?

This case demonstrates the ethical problems that have been created by hospital affiliations and competition.  We know hospitals want to keep patients within their “system,” especially the well insured.  A 70-year-old patient, with blunt trauma, would probably be in that category.  Our EMS crew demonstrated good assessment acumen and advocated for the patient. They were twice denied.

How could they circumvent this situation?  Outright ignoring the transfer orders would be too precarious, although possibly admirable.  They could have attempted to contact their Medical Director for an override, a reasonable alternative.  Or while en route to the initial receiving hospital, the radio communication could have “too much static and you are breaking up,” necessitating a decision to act in the patient’s best interest in the absence of medical control.  (Please do not let my medics know I said this!)

These patient care issues and dilemmas will continue to become more complicated.  As emergency physicians and EMS medical directors, we must transcend the politics and financial motivations and continue to do what we have always done, be advocates for our patients.

If you have any cases that you would like to present or be reviewed in The Pulse, please email them to us at  Thank you.