Under EMTALA, we're required to Triage, Provide a Medical Screening Examination and Stablize. Once a patient is deemed medically stable, we have fulfilled our EMTALA requirement. Although I know that doesn't end our obligation. What if after the Medical Sceening Exam it's determined that the patient is NOT SICK? Are we in terms of Civil and Ethical Practice basis required to provide care for them?
Here's my real world example. A patient's chief complaint was Fever 98.9 degrees and Rhinitis for 30 minutes prior to arrival, no history, no medications, no other complaints, no other symptoms, no recent travel, no sick exposures. Just was worried that he or she was coming down with the Swine Flu that had been in the Media. The CDC recommends that we only do Viral Swabs for H1N1 if the patient is very symptomatic, very sick and will be admitted to the Hospital, we are not to do a swab on every single person who is concerned about H1N1. We get these presentations constantly, I believe due to the Media coverage of the Swine Flu.
This is one doctor's regular approach: Viral Swab for Influenza, IV, IV fluids 1 Liter, Labs- CBC, Chem Panel and Urinalysis and Tylenol orally, then repeat vital signs per protocol (for him, it's every 15-30 minutes). Prescription home for Sudafed, Motrin and Tylenol.
Another doctor sees this as a Not Sick patient, and will discharge this patient home with the recommendation of Tylenol and Ibuprofen if a Fever does start, and to see the Primary Doctor in a few days just for follow up.
Which doctor's treatment is Right? I say doctor #2's treatment was more Ethical as the patient was Not Sick and hence, we should not treat someone who is Not Sick, that is part of our obligation. Although Doctor#1 would never be sued due to he covered every possible base imaginable, while doctor #2 could have complaints from people who didn't feel enough was done. Are we obliged to do, or should we do Diagnostics, Medications and Prescripations for Not Sick people? Is Legal Medical Practice, ie: what was done by doctor #1, where a doctor is so worried about a Lawsuit that his or her orders, even if not clinically indicated, will cover ever possible Legal Base, Right?
I think it's weird someone would come in with rhinitis for 30 minutes prior to arrival. It would take 30 minutes to walk to the car, drive to the ED, and park. Then you have to check in, wait for triage, if there is anybody else there who's really sick, I would think Mr. 98.9 would be waiting a VERY long time. Of course, if there was nobody there and that's why the doctor has so much extra time on his hands, it would make great sense.
He must've been really afraid of H1N1, to go through the hell of an ED visit for nothing... and within 30 minutes of getting the sniffles? Very odd... Seems he would've, at least, lied and said he'd been sick for a day or two. :icon_roll
It happens all the time -- patients with some minor symptom for a very short period of time. Either that, or XYZ symptom x 10 months, and they felt compelled to have it checked at 2 a.m. :)
Patients lie all the time, what justifies arresting them?
We had 2 frequent fliers arrested recently who had been hospital hopping using different names. Forgot which names they used where, got recognized ("hey, I thought your name was...) and buuuuusted. Charge was theft of service.
The sticky issue here is that EMTALA requires that you perform a medical screening exam. However, once you do that, you have duty. It doesn't matter whether you stabilize them under EMTALA, they are now your patient. So, for example, a patient comes in after falling off a bike with "roadrash". The doctor discharges them but nobody cleans up their scrapes or gives them adequate follow-up instructions. If one of those get infected and requires further care, you can still be liable. It may not be an EMTALA violation, but it can still be covered under state tort laws. So even if they don't have an emergency medical condition, you still have to provide the current standard of care.
The sticky issue here is that EMTALA requires that you perform a medical screening exam. However, once you do that, you have duty. It doesn't matter whether you stabilize them under EMTALA, they are now your patient. So, for example, a patient comes in after falling off a bike with "roadrash". The doctor discharges them but nobody cleans up their scrapes or gives them adequate follow-up instructions. If one of those get infected and requires further care, you can still be liable. It may not be an EMTALA violation, but it can still be covered under state tort laws. So even if they don't have an emergency medical condition, you still have to provide the current standard of care.
but this is not the sort of thing the OP was asking about...
but this is not the sort of thing the OP was asking about...
Her questions is whether we have to treat someone who she feels is not sick. The answer to that questions is: yes. EMTALA, which she initially discussed, only requires that you stabilize a person. However, you still have to treat someone once you see them, because this is the standard of care. It doesn't matter whether you are in an ER or a doctor's office. Although sending a patient like the one in the example home would probably not be below the standard of care, you always take some risk with minimal treatment.
Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
Her questions is whether we have to treat someone who she feels is not sick. The answer to that questions is: yes. EMTALA, which she initially discussed, only requires that you stabilize a person. However, you still have to treat someone once you see them, because this is the standard of care. It doesn't matter whether you are in an ER or a doctor's office. Although sending a patient like the one in the example home would probably not be below the standard of care, you always take some risk with minimal treatment.
Please give me a authoritative citation/reference where you are getting that this "standard of care" to treat everyone exists? I'm very interested in whatever reference you can cite.
Just because "everyone does it" does not make it "standard of care"....
If everyone is doing it "wrong" then you establish the wrong standard of care....
I LOVE the ER's I have worked where they have established a "medical screening exam". That's all you are truly entitled to under EMTALA.
There are SOME complaints identified as exclusions but the system works AND has been held up in court.
Patient comes in with whatever minor complaint you want to insert here. A Dr, PA or NP sees the patient, determines if there is a medical emergency.
Yes- right this way please.
No- Sorry you need to see your Doctor. Bu-Bye!
You're right! That's what our ER does, and we haven't had much of a problem with it. Some of the _____ people come to the ER with, and when a trauma comes in and you are having to move patients to get the critical pt in to be treated.
Some of our patients have the most ignorant of reasons. Some say "Well, my MD is busy and I didn't want to bother him with this. I figured you guys could handle this."
We've had patients come in in the middle of the day with a toothache - not abcessed, no fever, ect. and they haven't even tried to call and see their dentist. And I feel their pain on this one, I HATE toothaches and even going to the dentist, but I wouldn't tie up an ER with it unless I just had to. We have had some come to the ER wanting an MD excuse after they skipped a day of work or school and claimed to be sick. They weren't seen or even come to the ER with it, but want an excuse anyway. The ER docs I work with LOVE that one.
It is great using the MSE and sending them on their way to the MD or dentist, ect if appropriate.
Please give me a authoritative citation/reference where you are getting that this "standard of care" to treat everyone exists? I'm very interested in whatever reference you can cite.
Just because "everyone does it" does not make it "standard of care"....
If everyone is doing it "wrong" then you establish the wrong standard of care....
Please explain.
The standard of care can come from anywhere. When she asked whether or not we have to treat someone who is not sick, that depends on what she means by "have to treat." The statutory law only says we have to screen and stabilize. However, in terms of medical malpractice and negligence, we do have to treat. The "standard of care" is whatever a jury says it is. If the patient in her example sued then the defense is going to put on 50 doctor #1's who are going to argue that it is the standard of care. In her example, I doubt that there would be any type of liability. But in closer cases you have to be careful when you have the cowboy attending who just sends everyone home. In med mal cases you have to remember that any jury will be one of regular people who don't see BS every day of their lives and don't really understand why you don't get antibiotics when you have a viral infection. The patient/plaintiff is just going to tell them something that they can all relate to: I went to the hospital, and they didn't do anything for me. Not saying I agree with it or that it will work in all cases, just saying that we have to be careful about simply discharging all of those nonsense complaints. The good thing for us is that this is more of a medical decision.
The doctor has to make the determination if the patient is emergent or not. Since opinion differs with each doctor, they are both right (although I'm with you, the patient didn't need an iv etc). The media has done the public another huge disservice with all the hubub about swine flu.
Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
The standard of care can come from anywhere. When she asked whether or not we have to treat someone who is not sick, that depends on what she means by "have to treat." The statutory law only says we have to screen and stabilize. However, in terms of medical malpractice and negligence, we do have to treat. The "standard of care" is whatever a jury says it is. If the patient in her example sued then the defense is going to put on 50 doctor #1's who are going to argue that it is the standard of care. .
"Standard of care" is defined by experts, professionals, professional organizations, educational entities and peer leaders.
"Expectation of care" is defined by the public at large and what they perceive as what should be done - the public (nor the jury) sets the standard. The jury may subcumb to it at the hands of a skillful prosecution or defence, but precedence is NOT set in the courtroom which establishes "standard of care"...some lawyers may tell you that it does, but it does't.... the experts (et al) set and re-establish the standard during each testimony.
PS: you still haven't given me any citations or references for your statements...
Miss Chybil RN, BSN, RN
318 Posts
I think it's weird someone would come in with rhinitis for 30 minutes prior to arrival. It would take 30 minutes to walk to the car, drive to the ED, and park. Then you have to check in, wait for triage, if there is anybody else there who's really sick, I would think Mr. 98.9 would be waiting a VERY long time. Of course, if there was nobody there and that's why the doctor has so much extra time on his hands, it would make great sense.
He must've been really afraid of H1N1, to go through the hell of an ED visit for nothing... and within 30 minutes of getting the sniffles? Very odd... Seems he would've, at least, lied and said he'd been sick for a day or two. :icon_roll