From Nervous in Nebraska

May 5, 2007

Dear Paw Paw:

Last week a 28 year old woman who is G8, P7 at 39 6/7 weeks gestation presented to our ED saying she was in labor. Her water broke at home and she was having contractions every 4 minutes. Dr. Dorch examined her and told her, “You are only 6 cm dilated. I don’t do Obstetrics and you need to go somewhere else.” He discharged her from our ED and told her to go to one of the large hospitals about 45 minutes away. She was quite dismayed, but got into her Gremlin with her husband and 7 children and drove away. I and the rest of the nurses thought this might be an EMTALA violation. What should we have done?
Nervous in Nebraska

Dear Nervous:

Next time Dr. Dork tries to pull a stunt like this take a metal bedpan and whack him over the head until his toes bleed. Of course this is an EMTALA violation. What does he think EMTALA is? Something you get at Taco Bell? He ain’t Prissy from GWTW and he needs to know ‘somethin bout birthin babies’ if he is going to work in the ED!

EMTALA is a law and violations are crimes. This means he could face the following penalties:

1. Termination from Medicare and Medicaid
2. Fines of up to $50,000 per violation
3. Criminal prosecution or lawsuit under the Civil Rights Act if a patient says that the EMTALA
violation was based on discrimination
4. Suspension of Medical Staff privileges
5. He could be reported to the State Medical Board and NPDB
6. Investigated by State PRO or Licensure Board for questions about his quality of care

In short, his career, livelihood, and finances would be toast. No his liability insurance will not pay or provide him with legal assistance. The hospital can be fined and lose ability to see Medicare patients too. If that were to happen the hospital is essentially out of business. The hospital could seek to collect damages from him as a result of his violations.

For patients in labor, EMATLA requires that he perform a screening exam, provide treatment and meet all transfer requirements. Usually the patient(s) needs to be stabilized which means delivery of the infant. CMS has decided that all emergency departments are capable of delivering full term uncomplicated deliveries, whether the hospital provides obstetric services or not. If the hospital does not offer obstetric services transfer may be an option, but only if it can be done safely and properly. A Gremlin is not a proper mode of transport for anyone, a Porsche maybe, but a Gremlin never. This woman deserves a medal for being able to fit herself, hubby and 7 kids into one.

The transfer form must state why the patient needs more advanced services. Transfer of women in labor may be acceptable only if she requests the transfer or if the physician certifies that the benefits outweigh the risks. What you describe is one of the more common EMTALA violations. It often results in citations. You can not discharge a patient (any patient) and tell them to go to another hospital for care.

Next time refuse to discharge the lady, and call someone with at least ½ an ounce of sense to come and take care of the woman. If necessary call your ED Nurse Manager, DON, ED Medical Director or the largest employee in the hospital to come and sit on Dr. Dork while you and the rest of your team do his job for him.
Paw Paw