Doctor's Orders & Intra-Transfer Modifications Of Care.

You get called out to transport a sick trauma patient from the local community hospital to the trauma center and prior to leaving the outside facility you get verbal report from the RN, a pile of paperwork, and an order sheet from the referring doctor. You don’t fully agree with these orders and can think of some alternatives which might benefit the patient or, better yet, notice a safety issue.

So what do you do? Can you change these orders?

Who is in charge of the patients care medico-legally throughout the transport?

How do you get across your message or concerns?

What is your best course of action?

First of all, it is important to understand why this patient is being transferred.

It’s not because the referring physician doesn’t know what to do nor because they can’t handle this complex patient yet, rather, because there are services at a tertiary care center that this patient needs that are not available at their facility. For trauma, this means surgeons in-house, REBOA, neurosurgeons in-house, orthopedic surgeons, vascular surgeons, cardiothoracic surgeons, and more OR space and specialty trained providers available (burn APPs, trauma nurses, peds specialist, peds RTs, etc etc).

For the sick medical patient, it might be intensivist care and ICU care (RNs, RTs, ICU pharmacists) that would not be available at that outside facility. It could also be certain specialty consultant services such as on-site GI, hepatology, transplant services with specialty labs that can be checked daily (think tacrolimus levels), endocrine, ECMO, or specialty OBGYN. This list could go on and on.

Just like there are a variety of EMS providers and CCT providers with different levels of experience there are also EM physicians with different levels of experience. It is important to understand, however, that most EM physicians have the same basic education which, to call it basic, is a misnomer. Most EM physicians are board certified in emergency medicine which means they completed high school, 4 years of undergraduate college education, 4 years of medical school, 3+ years of residency training with detailed requirements on what was covered/skills completed/specialty testing/rotations and completed a national exam which includes written and practical evaluations. If they are working in an ED then they have also been credentialed which means that an outside party has validated all of their experience, schooling, skills, and training. I can only speak about my own experience but in residency alone I saw at minimum 4,000 patients that I treated and cared for within a 3 year span (yes, they keep track of those numbers and this was ED patients alone).

Also, keep in mind that before a patient can be transferred from one facility to another there has been a discussion and agreement between the referring (sending) physician and the receiving (accepting) physician. The patient’s case, labs, predicted treatments, and plan-of-care have been discussed and agreed upon. Even in emergency cases where a patient is being transferred to another ED, this discussion has taken place prior to transfer.

I am not a lawyer and this is not legal advice, yet my understanding is that per EMTALA, the burden of responsibility for patient care is usually on the referring physician until arrival of that patient to the receiving facility and the receiving physician. This referring physician is also the one who makes the ultimate transport decision and decision on mode of transport. Now while it is legally acceptable, and some might say indicated, that the referring physician manage the care of that patient under EMTALA until arrival of the patient to the receiving facility, this is not always practical and thus there are standard operating procedures/protocols in place as well as on-line medical control.

EMTALA was initially drafted to avoid "dumping" of high-risk and/or uninsured patients onto other hospital systems.  The drafters of EMTALA didn't anticipate a scenario like what we have today where hospitals and transport programs would be competing to get these patients.  The original idea was to ensure that patients received care and were simply not being shipped out to have someone else deal with them.

For the purposes of EMTALA a "transfer" is defined as "the movement of an individual outside a hospital's facilities at the direction of any person employed by the hospital. So by applying this definition, it is a fair assumption that the person who called for the transport wants to transfer the care of the patient to someone else.

Additionally, EMTALA states that such transfers must be effectuated "through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer.”

I have polled a couple of medical director friends of mine from different states and there is a difference in opinion on the matter of who is ultimately responsible for care of the patient in transfer. In most states transport orders are shared responsibilities. Some directors advocate that once the transporting team has taken over care and have departed the referring hospital, the transport crews may make changes according to their written protocols and they are encouraged to contact their own online medical control physician if they feel there needs to be a change in the plan. This change in plan would need to be relayed to the receiving physician/facility, as well, to make sure there is a smooth transition once arriving to their destination. The more orders given by the on-line medical director of the transport team, the more medico-legal responsibility that on-line director assumes. I encourage you to have an open discussion with your medical director about this since they will be the ones going to bat for you for an unexpected poor outcome.

What about the receiving physician? They can be contacted and consulted yet they have not established an official patient-physician relationship and they have not laid eyes on the patient and this is why most receiving physicians will usually leave the decision-making up to the referring physician. Some receiving physicians are willing to offer suggestions for care yet this is usually done on a physician-to-physician basis prior to arrival of your transport crew.

There is case law that enforces the idea that the referring physician is in control of the patient until they arrive at definitive care - Sterling v. Johns Hopkins is one of these cases (802 A.2d 440 - STERLING v. JOHNS HOPKINS HOSPITAL, Court of Special Appeals of Maryland.).  Sterling v Hopkins is really about when a physician-patient relationship is established, but address many of the EMTALA questions that come up in transport.  

The Maryland court held that "a hospital accepting a transfer owes the same duties as the transferring hospital, as the accepting hospital is not currently treating the patient and thus has not established a responsibility toward the patient. Furthermore, the accepting hospital is unable to examine the patient to make informed decisions.” So, Hopkins owed no duty of care to Sterling because, in the court’s view, a physician–patient relationship was not created and treatment of complications that ultimately resulted in a patient’s death. For this reason, receiving physicians may be less willing to make changes to a set plan for the patient in transport.

EM Physicians do have the extra stressors of dealing with multiple patients at a time and human factors can affect decision-making so it is important to not blindly follow orders especially if you think that there is an order that might negatively affect the patient.

It is always important to keep in mind beneficence and non-maleficence. Beneficence is the cardinal principle defined as the obligation of the health care providers to strive to aid the patient. Non-maleficence is the obligation of the health care providers to avoid harming the patient. All of this extends back to ancient times as expressed in the statement Primum non Nocere – first, do no harm. Treatment protocols and orders for transport can create great ethical tension among the members of the transport team obligated to care for a patient in a manner they may perceive as non-beneficent.

Occasionally conflicts about medical decision-making may arise between the referring provider and the protocols or clinical judgement of the transport team, regarding the medical care necessary prior to beginning transport.

In these cases, good communication will usually suffice to resolve the conflict. Bring this discussion directly to the referring physician and make sure to do this with an open mind and away from the patient and their family. Remember that relationships are important in this field and be prepare to defend your suggestions, actions, as well as, your attitude.

Now all that being said, the transport and CCT provider has more experience within that transport environment and understands the stresses of that environment. As medical professionals it may be important for us to relay that respectfully and in a humble fashion.

A moving ambulance or helicopter is an environment with increased stimulation, noise, and vibration in which patients will most likely have an increased requirement for analgesia and sedation. Size and weight limitations can restrict crew configuration and equipment available for the transfer, thus sometimes limiting the amount of drips or medications that can be running simultaneously.

One main difference that I have noticed in transporting patients compared to treating them in the ED is that I usually end up using higher doses of analgesia and sedation given the stimulating environment of transport. This is counter balanced by the fact that in the transport environment I am focused on one patient in real time and watching their vitals every second. This is in stark contrast to the ED environment where I write for an order, the medication is administered by a nurse, and I recheck the patient 15 minutes later.

This now brings me to the point of finesse and effective communication.

The goal is to care for this patient and get them to them transferred safely. Make sure that any changes suggested are patient-centered and not simply for your own preference. Chances are that the referring physician has thought of these, maybe even tried some of them with no success, or a decision was made as to why this was not the best plan of action. For example, I’ve had patients that responded very poorly to 1 mg IV versed with extreme hypotension therefore different medications for sedation have been suggested or smaller doses.

Any concerns about transfer orders NEED to be discussed with the referring physician.

A good way to go about this would be in a private setting, AWAY from the patient, because the last thing you want to do is make that patient have less faith in their care providers. Undermining, humiliating, and throwing any health care provider under the bus simply makes you a D-bag. Don’t be a D-bag and ruin it for everyone else. Everyone is a customer and if you are unprofessional that behavior will reflect not only upon you but your agency and all other providers at your level.

Cliff Reid has an excellent post and podcast (Difficult Missions: The Hospital Primary) posted on December 18, 2017 at https://syndneyhems.com/2017/12/18/difficult-missions-the-hospital-primary/ regarding this type of situation. Keep in mind, that this is a different transport environment than what we have here in the United States and transfer of care is to a physician staffed retrieval team. Therefore legally they are transferring care from the referring physician to the flight physician. It’s still worth a listen and had some great tips.

Here are some examples of the suggestions for dealing with this type of situation based on the discussions in that podcast.

Tell the referring physician your concern and come up with some alternatives.

“I am concerned that the sedation parameters are not going to be sufficient for this patient given the stimulating environment in transit and I’d prefer more options or an alternate. What are your thoughts on trying ketamine at sedation doses or pain doses in addition to the fentanyl pushes the patient is getting? I’ve had good success with this in the past.” (They might have other options or know more about the patient’s history that might preclude this as an appropriate alternate.)

If this is a potential safety issue that you can clearly state to the referring physician that you are uncomfortable with a certain plan of action.

“I am uncomfortable with the idea of not starting potassium for this patient who is hypokalemic and on an insulin drip prior to transport given that the potassium will most likely shift into the cells with insulin administration. What are your thoughts on starting this prior to us leaving? Are there certain parameters you would like for us to follow en-route in order to help make that decision as to when to start this?” (It could be that the patient is in renal failure and that potassium has already been administered after the previous lab values and you would not know unless you asked. Sometimes this could be in the paperwork and sometimes it’s not because the EMR was printed prior to your arrival in preparation for transport.)

If there is a definite safety issue then say so to the physician in a respectful manner.

“Starting this antibiotic en-route will be a safety issue being that this patient is allergic to PCN and I am concerned they will go into anaphylaxis and uncomfortable with the administration of this medication.” (It could be that the patient was pre-medicated for this medication or that they recently had it and this was tolerated well. Once again, you won’t know unless you ask. Also, this could be a medication intolerance rather than an allergy and therefore safer for administration.)

What is an agreement cannot be reached?

The referring physician legally maintains medical control while the patient is inside the referring facility. It is poor form, to intubate a patient in a referring facility without having talked to the referring physician because as long as the patient is in that facility they are still under the care of that provider. If a patient is quickly desaturating, quickly contact that physician to come up with a good safe plan together. Sometimes it can help to say something along the lines of “Dr. Griffin, this patient seems to have major increased work of breathing and I’m concerned they are starting to tire out and will most likely need intubation en-route, can I assist you with setting up trial of BiPap prior to transfer or do you feel we should use this as DSI and set up intubation with this checklist I have here. With your back up, I’d love to take the 1st look?” A more passive approach can also be beneficial depending on the physician and you could simply state, “Dr. Griffin, can you come and take a look at the patient with me, since you’ve seen what they’ve looked like while in the ED… I’m concerned that their work of breathing might be increased or need intervention prior to transport?”

I have used this phrase in the past with consultants “I apologize that I might just not be communicating this well but my main concern is [state concern] and I’d like to know your thoughts on how we can address this and I am open to any suggestions you might have. I also feel that [insert med or procedure] might be a better or safer option, given that [restate any objective findings backing up your concern].”

Blend & Redirect Method

Another recent tip that I heard that might help is the “blend & redirect” method mentioned by Rob Orman from the ERCast Podcast ( blog.ercast.org/when-consultants-give-bad-advice/). You need to find something that you and the ordering/referring physician have a common ground on first, this is the art of blending. For example, “Dr. Griffin, I think we can agree that this patient needs sedation since they are intubated yet giving versed pushes seems to be tanking their pressure and requiring more levophed, don’t you think?”

Now that you’ve gotten that physician to agree, you are on the same page, and you can redirect them by asking about what they would suggest as the next step. “So what do you think we should try as an alternate?” You can say this, even though you know what the next step might be. Let them talk and then after they have given their suggestion, you can bring in your plan. “Dr. Griffin, I think propofol is an option for continued sedation like you mentioned but we might have to increase the pressor more or add another. How about trying a different sedation medication like a ketamine drip and seeing if that might work?” This way, you are both working towards the same common goal of a problem that you identified which might benefit the patient and you are getting your opportunity to make your case for changing their orders.

If these measures fail, you always have the option to contact your medical director as they are there to support you and may be able to facilitate with a physician to physician discussion. Your medical director has been trained in these methods and has a clearer understanding of both roles.

This is not a power play and this cannot be stressed enough. After all, it is about the patient and what is best for them. Changing a plan because you do not like it is different than changing a plan due to a safety issue. If you are changing a plan en-route by over-ruling a provider with more authority, you better be sure that this is the only way to protect the patient and be prepared to defend your decision making. So make sure that this is a legit fight and not just about style.

Where I work in the community, when transferring a patient, we have written orders for the transferring providers and I document how they are to titrate meds and at what parameters. I also have to include my phone number and if I am transferring control/orders then I have to include that person (could be another physician taking over for me or the receiving doctor). If these are unclear, then I always encourage the crews to contact me. I too have been on the other side, so I get it.

As, you can probably already see, this is not a clearly black and white issue. Saying that either a referring/receiving/medical director is “always or never” responsible for care throughout transport is bound to be inaccurate.

Here’s some of my own experience.

I have run into the case where a patient was too unstable for transport as a medic and as a flight physician. As I medic, back in the day, I had a discussion with the referring physician and had more pressors added and some meds changed around (like fentanyl/versed instead of Propofol… before the days of ketamine). I have also run into the case where the patient was just too unstable for transfer and required blood & FFP prior to transport. I had to call my medical director and explain the situation and why I was refusing to take the patient because it was unsafe. After a discussion with my medical director and the referring physician they understood that we didn’t have blood at our disposal and this was rectified. This was a decision I had to make and it was tough and it had to be reviewed. This is indeed one of the hardest parts of being a medic and advocating for our patients. I had to make sure to do this with humility so as not to ruin our relationship with the referring provider. You want them to call you back and you want them to know that you are on the same team.

Now, as a flight physician, I have also had this same type of case and after consultation with the referring ED doc on a severely traumatized patient it was understood that the patient had a high likelihood of death en-route. Once again, this is a different type of scenario given I am taking over legal medical control of that patient as a physician. The surgeon at the outside hospital refused to take this patient to the OR and wanted them transferred to the trauma center. It was clear to all parties that the surgeon had refused and the only other option was transfer to another surgeon willing to operate. In this instance, the ED doc can’t perform surgery and blood, FFP, PLTs, TXA, fluids, and US were all being utilized. What this patient needed most was damage control resuscitation in the OR and it was my job to get them there. So, I bit the bullet, knowing there was no other option and optimized what I could en-route. This patient survived the transport although ultimately died within 24-48hrs due to their major injuries and massive trauma. This case was tough and has ultimately been my impetus to continue advance EM care & EMS providers and look into other options that could have saved this patient such REBOA. But that’s a blog for another day.