Not Appropriate

It is always a question whether I should write about "horror stories" or not. The truth is, for every mishap, I could name a dozen wonderful things I've observed, things I did not expect, things that were brilliant and kind and generous and altruistic. Furthermore, when I talk about things that could have been done better, I do my profession and the institutions I work for no favor. For the most part, there are many ways to skin a cat and a lot of different approaches to the same problem. But last night on call, we took care of a patient who was not treated appropriately by a transferring facility.

Interfacility transfers are a tricky business. A physician at an outside hospital, usually a community hospital without the array of resources of an academic center, identifies a need for a patient that can't be provided at that facility. She then finds an accepting physician at a facility which can provide that service. The patient is transported over, we provide that service and take care of him. Thus, we see transfers for a wide variety of patients: obscure cancers, organ transplants, complex surgeries.

Long story short, a patient was sent from a hospital several hours away in a regular gurney ambulance with 2 EMTs. Our accepting physician confirmed the patient's story and that he was stable for transport. However, it seems that immediately prior to transport, the patient's oxygenation requirements went up considerably from 2 liters of nasal cannula to 10 liters of nonrebreather facemask. The outside facility still continued to transport the patient, and instead of upgrading him to an ICU level ambulance, kept him in a gurney ambulance where his O2 sat could not be measured and a facemask could not be applied. They turned his nasal cannula up at the highest setting and sent him on this 4 hour ride. Near the end of the journey, they ran out of oxygen, and when they pulled up to our hospital, the patient was air hungry, breathing rapidly, and slightly confused with an O2 saturation of 60% (normal would be >95%).

This was a gross error, and we let that facility know. Transport issues are the liability of the sending hospital, but all of us involved want to do the right thing for the patient. We had to meet the patient in the ICU with an ICU team and nurses ready, knowing that his breathing might be in trouble. Again, as I have said many times in this blog, transitions of patient care teams are critical moments, and we really need to be careful to keep patients safe.