Weiss: EMTALA- What the Intensivist needs to know!

Today we welcome the brilliant mind of Larry D. Weiss M.D., J.D. for an afternoon not to be missed. Dr. Weiss has been a staple for legal-based lectures for the last 16 years here at the University of Maryland where he acts as a Professor of Emergency Medicine. Although Dr. Weiss stopped actively practicing law years ago, he is one of the foremost experts in his field as he has been called to all corners of the world to speak on health policy and risk reduction. I highly recommend that you take the time to soak in only a brief sampling of his infinite wisdom!

Clinical Pearls

  • Obligations per EMTALA:
    • Medical Screening Exam (MSE) in order to “diagnose emergency medical conditions (EMC)”
    • Stabilization
      • Loop hole: EMTALA does not predict inappropriate transfers of stable patients
    • Appropriately transfer to a “higher level of care”
  • Patients can only sue hospitals for EMTALA violations, however physicians can be fined up to 50k per violation
  • Early Cases:
    • Vickers v. Nash
      • Intoxicated patient with head trauma, observed x 11 hours, laceration closed, D/C, dead 4 days later s/p EDH
      • EMTALA violation suspected, however negligence has nothing to do with EMTALA
    • Green v. Toro
      • If a patient is stable” EMTALA does not apply
  • Transfers:
    • Patient or family request w/ informed consent
      • Can allow even an unstable patient to transfer
    • An oath/certification signed by a physician that the medical benefits outweigh the risks
    • The Transfer must be appropriate
      • Max potential to stabilization by the sending facility
      • Receiving facility has: space + personnel for care & accepts transfer
    • Must send appropriate medical records + qualified personnel and equipment travel with patient, AND we have a duty to report violations or face a fine
    • Smith v Janes
      • Serious smoke inhalation, seen locally with obvious inhalational injury, transferred without intubation, respiratory failure/arrest, death
      • EMTALA violation suspected
        • MSE performed, however not stabilized
        • Proper personnel not used for transfer!
  • Misc provisions
    • “Reverse dumping”
      • If you have resources required for patient care but not available at the sending location, you must accept!
      • St. Anthony v DHHS
        • St. Anthony hospital rejected an appropriate transfer
  • Sterling v Johns Hopkins
    • Preeclampsia, accepted at JHH, sent by ground, deteriorates en route, diverted to a community hospital, then flown to JHH, again deteriorates and expires
    • Determined: When you are a receiving physician you have no legal obligation to patient care until the patient arrives 
      • However: When you take a more active role (recommend treatments or ask for imaging) you create liability and risks to yourself
  • 2003 Regulations
    • Law is written by Congress, then this law is delegated to a separate executive department to execute that law
    • Regulations are written by federal departments and agencies
    • Regulation: EMTALA does not imply to inpatients
    • Regulation: A physician can be on-call for multiple hospitals, but must find an alternative if they are unavailable (procedures)

Suggested Reading

  1. Zubai N, Weiss LD, Langdorf. Emergency Medical Treatment and Labor Act (EMTALA) 2002-15: Review of Office of Inspector General Patient Dumping Settlements. West J Emerg Med. 2016 May; 17(3): 245–251. [PubMed Link]
  2. Weiss. EMTALA: Focus on Critical Care. [Direct Link to Handout]
  3. Weiss LD, Martinez JA. Fixing EMTALA: what’s wrong with the Patient Transfer Act. J Public Health Policy. 1999;20(3):335-47. [PubMed Link]
About the Author

Jim Lantry

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Just your average critical care doc: Wandering the ED and ICUs for the USAF down in the San Antonio Military Medical Center, traveling the globe to cannulate for ECLS wherever the need arises, and trying to keep up with great minds of today. E: JlantryMD@gmail.com

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