Transfer Center II

This is a continuation of the post several days ago.

EMTALA is a law that often comes into play when interacting with the transfer center. If a patient at an another emergency department has medical needs that exceed the capability or capacity of that hospital, then we cannot decline the transfer (unless we feel that the patient will die en route or we don't have the capability or capacity to care for him).

I initially thought that an EMTALA call would be a no-brainer; my hands were tied so I'd take the patient. But it turns out this isn't always that clear-cut. A physician from an outside emergency department calls with an EMTALA request; a patient with septic shock from pneumonia needs intensive care. However, when I probe further, I find out that not only does that other hospital have an intensive care unit, but the patient may not need ICU level care in the first place. After two liters of fluid resuscitation, the patient's vital signs were normal and he had no evidence of end organ damage. When I directly asked the ED physician whether they really had resources to care for this patient, he admitted that he was not EMTALA. Needless to say, all transfer center calls are recorded.

Sometimes transfers are accepted because the patient is "ours." For example, one of our pre-liver transplant patients showed up at an East Bay hospital with hepatic encephalopathy. Although the hospital was perfectly capable of caring for that patient, out of courtesy, they let us know. This type of transfer, to me, is a preferable but non-urgent one. Depending on our bed situation and how adamant the hepatologist is, I could accept or defer that patient.

Other times, we want to make a patient "ours." A patient is referred to us because of an acute leukemia and disseminated intravascular coagulation. Our hematologist believes that getting the patient over to Stanford may really be that colloquial "life or death" difference. In that case, I do my best to make the transfer happen.

Ultimately, a lot of considerations - medical, ethical, resource-management, and legal - play into the calculation of whether to take a patient from another hospital to our medical ICU. It's something I look forward to learning, and a real challenge, especially since our beds are limited. I don't want to take a bed for a transfer and end up short on beds if multiple codes happen or the ED fills up with critically ill patients. Yet I don't want to deny someone else the chance to receive care here if it is necessary.