EMTALA and bypassing a hospital

[u/Dowcastle-medic]

So I had a pt today totally stable but she has an injury I know the local type 4 community hospital (20min) is not going to be able to fix. It was suggested by the clinic staff where I picked her up to go to the type 3, 1.5 hours away. But one of the ER drs for the community hospital happened to be there and looked at the injury and said no just take her to our hospital.

She said the type 3 couldn’t deal with that either and she would need to go to One 3.5 hours away so go and get her c spine cleared…

So we did and then I get chewed out by the ER drs on call saying I can NEVER bypass them based on EMTALA. I always have to stop and let them stabilize the pt and cat scan and such…

That’s not true is it?

[u/tacmed85]

As others have said EMTALA doesn't apply to us. That said dropping a 911 unit from a system for 3+hrs especially in what I presume is a pretty rural area without a lot of resources is a big decision and shouldn't be made lightly. In the vast majority of cases in that scenario I'm going to the local ER and letting them sort things out from there.

[u/Dweide_Schrude → u/tacmed85]

This is always challenging in a resource limited system. We are “rural” with a 10k population in our district. Fortunately we have two Level 1 (1 of those is peds Level 1 as well) and three Level II all within 30min of the farthest point of our district.

Most of the overrides I do are for PCI/Comprehensive stroke patients.

As long as documentation is in place and you justify it in the narrative it should be fine.

[u/tacmed85 → u/Dweide_Schrude]

As long as documentation is in place and you justify it in the narrative it should be fine.

It's not a matter of "being fine" it's a matter of doing what's right for the system. In a resource limited area like it or not every call and decision is a triage decision. 30 min like in your example isn't as big a deal, but OP is talking about dropping system resources for 3-7 hours. That's a ton of time where a lot can happen and people with serious issues could be left with a severely delayed response depending on resource location and quantity. The first agency I worked for in rural Utah had a similar problem in that we had one ER with pretty limited capabilities, but our closest trauma or specialty center was over 2 hours away. There was only one ambulance staffed by full time employees for the entire county so if we weren't available they'd have to page out our volunteers who responded from home to the station to pick up an ambulance and finally to the call creating a massive delay and lower level of care(usually ILS). Our closest potential mutual aid was 45+ minutes away so that really wasn't an option either. The policy there was everyone gets transported to the local ER and then they can fly them out or whatever they need to do. It sucks on the patient's side if the complaint isn't that time sensitive and they're getting a flight bill now, but it was realistically the only viable way to do it. Sure it's only about 10K people in the county, but that's still plenty for more than one to need help while the primary unit is tied up especially if we were taking 4 hours to run a single call.