Operations, Patient Care, Training

Think Before You Transfer

Issue 8 and Volume 36.

It’s just after midnight when a Honda Civic pulls into the parking lot of a community hospital. There’s a light breeze, and the temperature is near freezing. Two people help a robed woman out of the front seat of the car, walk with her to the emergency department (ED) entrance and leave her at a reception desk. Her gait is wobbly, so the receptionist seats her in a wheelchair.

The lady’s name is Helen. She’s in her 60s. She’s clothed in men’s pajamas that are too big and a terry cloth bathrobe that reaches just past her knees. Even indoors she’s obviously not warm enough; she keeps her knees clamped together and the bathrobe wrapped snugly around her.

She can’t explain why her neighbors brought her to the hospital. Her face appears lightly bruised, although her skin isn’t broken and there’s no swelling. She chatters without pause about things that don’t seem relevant to the situation: her third-grade teacher, her native town in Iowa and the sounds of trains. She appears lucid but never stops talking. That seems to irritate one of the nurses, who almost shouts in an effort to get her to “relax.”

A physician questions and examines her. She says she hasn’t been able to sleep for the past three weeks because of a right-sided temporal headache, and she admits to some episodes of double vision during that time. She reports having had “migraines” for the past year, but none that lasted this long. She further states that it’s possible she had an unwitnessed seizure four days ago, with some loss of consciousness after which she remembers waking up on the floor of her home.

She lives with a male companion who became enraged and locked her out of their house because she “wouldn’t shut up.” Other than the facial bruising, her exam is unremarkable. She seems to have no other pertinent history, meds or allergies, and she hasn’t seen a physician in more than five years.

The emergency physician specifies a neurological consult, then returns to the physician’s lounge to take a snooze. The ED is empty. There are beds upstairs, but neuro coverage won’t be available until 9 a.m. the following day. Even then, a neurosurgical candidate would need to go elsewhere. At 1:50 a.m., the staff starts calling for an ambulance to transfer her.

Private ambulance services in the area screen their transfers for insurance coverage, and down staff at night. One service says it can be available in four hours, but if they get busy during that time, it may take longer. So the ED nurse upgrades the transfer to emergency status and dials 9-1-1 for a medic unit.

Steele Stevens and his partner, Buddy, are asleep in quarters when the call comes in. They’re one of two crews tonight providing 9-1-1 ALS transport coverage for their town of 30,000. They work 24-hour shifts, and they’ve already had two wake-ups. For whoever drives, this will be a monotonous 30-mile transport. “Thank God,” says the nurse when they arrive. “Get this lady out of here; she’s driving us nuts.”

I’ve talked before in this column about a field rule you shouldn’t break, Life-Saver. It’s a good rule, too: Never do anything you know is stupid.

I want to make sure nobody misunderstands me about this, so I’m going to break another rule, one they teach writers: Lay off the caps lock key. Ready? WE DO TOO MANY NIGHTTIME TRANSFERS.

There are exceptions to most rules, even good ones. When a patient comes into a community ED in the middle of the night with major trauma, a stroke, an ST-elevation myocardial infarction, an abruptio or something like that, then yes, they may need to be transferred in the middle of the night.

Otherwise, I think nighttime transfers of non-critical patients are voodoo medicine. They’re bad for 24-hour crews. And they’re bad for these patients—who always end up forfeiting a whole night’s sleep, being dragged unclothed into the cold night air, being interrogated at a second receiving facility and then paying for the privilege.

You know a physician specialist isn’t going to see a patient like Helen until after 9 or 10 a.m. In the meantime, why not feed her, let her get some sleep and give her some time to shower and brush her teeth? Then, turn her over to a crew who’s awake enough to drive (and be nice to her).

By the way, I just thought of another good rule. If you hate your job, do something else. (Can’t think of an exception to that one.) JEMS

This article originally appeared in August 2011 JEMS as “Three Good Rules: Do we transfer too many patients at night?”