When the Shuttle Service is Not a Courtesy

Training your office staff to follow through on details is part of any competent physician’s routine. But the staff’s handling of an emergency is closely tied to the physician’s own actions in an urgent situation.

Dr. IM, an internist, had been treating his 76-year-old patient for eight years. The patient had a history of high blood pressure, high cholesterol, degenerative joint disease of the back, and vertigo. One summer day, the patient came in to see Dr. IM complaining of difficulty breathing the evening before and chest pressure that he described as “an elephant sitting on my chest.”

Objectively, the patient had no symptoms, but his blood pressure was elevated. Dr. IM ordered an EKG done in the office. When the test showed a right bundle branch block and T-wave abnormalities, Dr. IM believed the patient was having a myocardial infarction. He called the nearby hospital and notified the emergency room of the patient’s impending arrival. Dr. IM also informed the hospitalist of the patient’s condition.

Dr. IM told the patient of his diagnosis, gave him nitroglycerine to reduce his blood pressure, and instructed him to wait in front of the office building for the hospital van to transport him 200 feet to the emergency room. Dr. IM also instructed his medical assistant to contact the hospital transportation office to notify those in charge of the patient’s transit needs. When a van driver inexplicably told the patient to wait for the next van, the patient complained to Dr. IM’s medical assistant. The medical assistant, who was not aware of the patient’s diagnosis, called the van service again.

When the shuttle still failed so show up, the patient used his cell phone to call his family. The family members went straight to the emergency room, which still had not yet received the patient. The patient’s wife and brother-in-law then drove over to the medical office, where they found the distraught patient still waiting. They took the gentleman to the ER. Dr. IM remained unaware of any of the patient’s transit problems.

The emergency room physician formed the impression of an acute myocardial infarction, hypertension, and transient ischemic attack, status post back surgery. The patient was admitted to the hospital by a cardiologist via the cardiac catheterization laboratory. When the patient underwent a cardiac catheterization that evening, the cardiologist found a partial occlusion of a small diagonal branch vessel.

Was there a staff training problem here? Given that the medical assistant was not aware of the patient’s diagnosis, her actions were not all that unexpected.

But should Dr. IM have ended his own attention to the patient after turning him over to the medical assistant, especially without a clear explanation of the patient’s condition? And what about the decision to rely on the shuttle van in the first place? Doesn’t a likely heart attack call for an ambulance? One can surely anticipate that the operators of the courtesy van would not proclaim the service a substitute for emergency medical transit.

Several months after the incident, an attorney for the patient wrote to Dr. IM’s claims specialist at CAP demanding compensation for her client’s emotional distress. When an analysis of the medical records showed no sign that the patient suffered any injury from the delay in getting to the emergency room, the patient decided not to pursue the matter.

In a similar situation, calling 911 could have avoided such a question completely.

Gordon Ownby is general counsel at CAP-MPT.Comments on Case of the Month should be directed to gownby@cap-mpt.com