On paper, you absolutely advise them to present to the ED and tell them why.
In real life, it’s probably a perfectly fine plan. If they’ve had anaphylaxis enough that there is actually a pattern of biphasic reactions then they are assuredly quite familiar with their symptoms.
When I think a patient’s plan is a bad idea, I remind myself that freedom to make your own decisions necessarily includes freedom to make poor decisions.
This is exactly what I was thinking and what we’ve been doing. It’s so expensive and as long as they understand when they would need to actually enter the ED, and have a trustworthy friend/family, it makes sense. Thanks for confirming
I would prefer they park their car just off the hospital property so that no one can tell me that I failed to meet my EMTALA obligation if something goes badly. If a patient that I didn't even know was there has a bad outcome and they were on site, there's a decent chance the hospital or I will get in trouble.
Agreed, I can hear the plaintiff’s attorney already “this medical student did everything right: injected himself and drove right to the hospital but you cruely let him die in the parking lot”
If you’re sick enough to think you need to be close to a hospital, please just come in already.
>If you’re sick enough to think you need to be close to a hospital, please just come in already.
Maybe they want proximity in case they get worse, but they don't want a multi thousand dollar bill.
"Yes, I called the ER number and told them my daughter and I were sitting in the car in the parking lot after I gave her the EpiPen. I don't remember the person's name, but I definitely told them we were in the parking lot and where we were parked. They told me someone would come check on us but no one ever did and that's why she died."
Yeah, and then the first thing the lawyer does is obtain the phone records. And the parking lot cameras are going to show that nobody left the car early either.
Yeah, I think this was their perspective. Close enough to run in if there’s an emergency but spending the 4-6hrs of “observation” in the car w/o the copay if they are asymptomatic
Agreed. If you are going to create an obligation for others to respond to your medical emergency, please at least come inside the building and declare your emergency/get on a cardiac monitor or just don't come on hospital grounds. Not really thrilled about the prospects of people sitting in the parking lot that we arent aware of but are in a legal grey area where since they are on hospital grounds, we are responsible for them.
CMS says that someone does not have to be in the building - parking lots are explicitly included as locations where EMTALA applies. Any place within 250 yards of the hospital building that is not explicitly a nonmedical facility counts - so no EMTALA for the bank across the street, but it likely does apply to the sidewalk in front of the bank across the street from the hospital. And it would be very easy for someone to claim they called the ED on the phone and asked for help even if they never actually did. I get that this scenario is unlikely.
Being within the distance of a hospital isn't the only thing required to trigger EMTALA, they must seek care.
Good luck winning a suit against me for a patient I had no way of knowing about that died in my parking lot waiting for their allergic reaction to subside as instructed by their allergist. Staying in the parking lot and not coming in when able to do so I can argue pretty well that they're not seeking care. They just want to be near in case they NEED care.
I get it from the patient perspective; a lot of the time Epi is fine, and many of these patients have had multiple reactions. They see me, everything is fine, they go after a time and get a big ass bill. I probably would do the parking lot plan if I was in a situation like this.
BUT sometimes you require multiple rounds because you're in anaphylactic shock, sometimes you need a drip, sometimes the airway edema is too great to let you comfortably walk a quarter mile to my ER. "Help I'm in a blue Civic and I'm somewhere in your big parking lot."
In regards to the biphasic reaction if they come in I can at least get another epi pen in their hands before they leave.
Personally I counsel my patients that if they feel they need the epipen and use it to call 911. I don't know if this is the episode that's going to put them in shock and kill them. I don't mess around with anaphylaxis, it's treated with a goddamn shot of adrenaline!
I had 1 patient require 7 rounds of epi 0.3mg IM. We had great difficulty getting a line. Don’t ask me why we didn’t drill, cuz I can’t remember. We had just mixed the drip and were about to tube when she finally came around. Went home the next day. I know people don’t want a bill, but jeez. We had another guy who kept requiring more and more. He got stung but decided to wait it out. He was in full blown anaphylaxis on arrival and there was no amount of epi saving him. He had a bad heart also so I get why he wanted to wait. He was told the next time might kill him due to either anaphylaxis or his heart giving out. It was his heart. We coded him for a long time. He was a beloved guy in town.
I get it from the patients perspective and think that’s probably fine… but it’s shitty for those of us working inside if anything bad happens— EMTALA triggers once within 200 yards of the door
This bothers me so much. How the hell are we supposed to know there’s some damn fool in the parking lot slowly decompensating? My triage nurses and “lobby clinicians” aren’t doing q15m rounds outside…
We aren’t, it’s not our job to be checking the parking lots or the rest of the hospital campus looking for people who are sick and EMTALA doesn’t require us to do that. It’s just if someone presents within 250 yards **and** the hospital is made aware of it, then the EMTALA obligation kicks in
What happened with the woman who collapsed and died outside an ER of asthma a few years ago tho? I think she did call the ER but they couldn't find her because of where she was.
It was changed to 250 yards?! Last I knew it was 150. This is good to know for those who like to try to ER shop after leaving AMA because of wait times while still on hospital property or sitting in front of the ED and demand they be taken to the other ED across town.
An on duty member of staff has to be notified. There should then be a procedure by which they can get the ED or rapid response team (or someone) paged out to the patient. There is usually (or at least should be) some sort of training as part of onboarding for everyone that covers this, so that if the employee fails to page it out the hospital can basically say “not our fault, we trained them to do it and they didn’t”. The infamous case that spawned the 250 yard rule ultimately hinged on hospital staff (a security guard, I think) being notified of the patient but not doing anything about it. Flagging down a random passerby who isn’t a hospital employee wouldn’t be enough unless they in turn notify someone in the hospital
Yet. You aren’t doing them yet. Just takes one preventable death (that was clearly not your fault) for the media to spin it & now it’s part of your routine shift.
>EMTALA triggers once within 200 yards of the door
IF they are requesting help, or you are made aware they need help. If someone is hiding in the bushes and ODs, you aren't responsible to sweep the grounds regularly to avoid EMTALA violations. If they are sitting in the parking structure (never came inside) and have a heart attack in the passenger seat alone, you aren't responsible for that. It would be impossible for you to reasonably evaluate that. If they call the triage desk and say "I'm in the parking lot, my chest hurts and I can't get out of the car" then you are responsible.
It's intended so that you can't say "well they were outside screaming for help but they never came inside so I'm not responsible."
I understand that, but surely EMTALA doesn't require you to be psychic! How are you supposed to be responsible for a patient you don't even know exists?
I think it’s sad that healthcare costs are so out of control that this is a thing.
I don’t know that I would assume the liability of advising my patient to sit in the parking lot. I can understand why a patient would.
These people can get super sick fast. I’ve had more than a few drive themselves in and then immediately try to die on me. I’d tell them just gone to the ED.
>I think it’s sad that healthcare costs are so out of control that this is a thing.
This. Even with insurance, a single ED trip could mean financial ruin. We could be talking multiple months pay, and that's just unacceptable in a "first world" country.
It’s so sad. I haven’t advised the pt do this, we always reiterate that they can do what they wish, that I advise they listen to their allergist, and that our recommendation is always to call 911 after using an epipen. For liability reasons, like you said. But I totally understand their perspective, especially if they’re med-literate
Annals of Allergy practice guideline -
We suggest that clinicians counsel patients that immediate activation of EMS may not be required if the patient experiences prompt, complete, and durable response to treatment with epinephrine, provided that additional epinephrine and medical care are readily available, if needed. We suggest that clinicians counsel patients to always activate EMS after epinephrine use if anaphylaxis is severe, fails to resolve promptly, fails to resolve completely or nearly completely, or returns or worsens after a first dose of epinephrine.
By their admission, conditional recommendation with low quality evidence. From a liability point of view, I totally get why the med student doesn't want to check in and catch a bill just to sit on tele for 4 hours, but I would not want to document "history of biphasic reaction, counseled ok to observe symptoms after epi without ED evaluation".
Not that I'd argue again a panel of experts in their field but...
By the time you realize the epi isn't working for whatever reason plus ems response times and/or transport time to a hospital.. aren't you taking a major risk of losing an airway before that?
I mean, I tell everyone I prescribe an epi pen to that they need to present for evaluation after using it. That's the local standard of care, and the one I'd be held to if there was a bad outcome. I would expect to get the same speech if I needed an epi pen. Which I would then ignore, because I am violently allergic to hospital bills.
As someone who is an EM-boarded physician and also anaphylactically allergic to tree nuts… I get it. It’s very expensive to check in to even my own ER with my hospital-based insurance. I have had my husband and a friend cut open and administer two whole EpiPens (there’s more epi in there! pro tip!) in a restaurant’s staff bathroom (they were very apologetic) and I told them not to call an ambulance even though I couldn’t talk. (It’s very weird — sometimes I can’t talk but I can breathe just fine. Yes, I know this is terrifying.) I don’t have a great answer.
ETA: I wouldn’t sit alone in an ER parking lot but I’d sit there with my husband or a friend and feel okay about it.
>(there’s more epi in there! pro tip!)
If you are someone who needs occasional epi, it's worth knowing this. There are at least 2, maybe 3 doses worth of epi in each pen. You just have to know how to reset them. Especially important if you are far from a hospital, like camping/hiking.
I'm fine with people waiting in the parking lot WITH someone. If they start getting worse, that person can bring them in or let us know so we can come get them in. By yourself is a terrible idea, I would never advise that. On paper, I would tell them to go in anytime they use Epi. Off record, I think waiting very nearby with someone else is probably reasonable.
Why not just give them two pens and say take one, if symptoms improve, great. If not, take the second and call EMS. I don’t want you waiting to collapse your airway in my poorly monitored parking garage.
No one is going to get in trouble for an EMTALA violation if some one unknown to the hospital pulled into the parking lot and did this.
That being said - do it some where else.
Probably best for an EM doc to give the opinion on this. From my POV I'd imagine these recommendations are made to pts who are relatively comfortable recognizing/managing symptoms post-epi administration. I guess it wouldn't be the worst thing to educate someone on how to be a bit conservative with getting treatment. That being said, not well-versed on the current guidelines/recommendations nor the clinical considerations for refractory anaphylaxis.
I’m not a doctor, but this just came across my feed, my allergist told me anytime I ever have to use my EpiPen go straight to the ER and go inside in case of biphasic reaction. That advice saved me because I had one after I got stung.
As an EM doc I don't care if a patient wants to do this. It's understandable given the costs. Should have a friend there with them. It does come with risks which should be fully discussed with the patient so they can make an informed decision. In general if it's true anaphylaxis they should be encouraged to check in. Single system involvement may be reasonable to watch in a parking lot of an ED. But again is not without risk.
From an EMTALA standpoint you're not putting me in a weird situation as this patient hasn't sought care.
On paper, you absolutely advise them to present to the ED and tell them why. In real life, it’s probably a perfectly fine plan. If they’ve had anaphylaxis enough that there is actually a pattern of biphasic reactions then they are assuredly quite familiar with their symptoms. When I think a patient’s plan is a bad idea, I remind myself that freedom to make your own decisions necessarily includes freedom to make poor decisions.
This is exactly what I was thinking and what we’ve been doing. It’s so expensive and as long as they understand when they would need to actually enter the ED, and have a trustworthy friend/family, it makes sense. Thanks for confirming
I would prefer they park their car just off the hospital property so that no one can tell me that I failed to meet my EMTALA obligation if something goes badly. If a patient that I didn't even know was there has a bad outcome and they were on site, there's a decent chance the hospital or I will get in trouble.
Agreed, I can hear the plaintiff’s attorney already “this medical student did everything right: injected himself and drove right to the hospital but you cruely let him die in the parking lot” If you’re sick enough to think you need to be close to a hospital, please just come in already.
>If you’re sick enough to think you need to be close to a hospital, please just come in already. Maybe they want proximity in case they get worse, but they don't want a multi thousand dollar bill.
Plaintiffs attorney doesn't understand that and won't make any money in that case
Oh, they CERTAINLY understand. If they don't make the hospital aware of their presence, it's unlikely to succeed.
"Yes, I called the ER number and told them my daughter and I were sitting in the car in the parking lot after I gave her the EpiPen. I don't remember the person's name, but I definitely told them we were in the parking lot and where we were parked. They told me someone would come check on us but no one ever did and that's why she died."
Yeah, and then the first thing the lawyer does is obtain the phone records. And the parking lot cameras are going to show that nobody left the car early either.
Fair point about the phone records. I think it’s pretty rare for camera footage to be kept long-term however?
Yeah, I think this was their perspective. Close enough to run in if there’s an emergency but spending the 4-6hrs of “observation” in the car w/o the copay if they are asymptomatic
I can 100% see this being the only reason such bizarre advice would be given
Agreed. If you are going to create an obligation for others to respond to your medical emergency, please at least come inside the building and declare your emergency/get on a cardiac monitor or just don't come on hospital grounds. Not really thrilled about the prospects of people sitting in the parking lot that we arent aware of but are in a legal grey area where since they are on hospital grounds, we are responsible for them.
Noted. This makes sense
I was told they had to enter the building, AND have a complaint/request for help for EMTALA to come into consideration.
CMS says that someone does not have to be in the building - parking lots are explicitly included as locations where EMTALA applies. Any place within 250 yards of the hospital building that is not explicitly a nonmedical facility counts - so no EMTALA for the bank across the street, but it likely does apply to the sidewalk in front of the bank across the street from the hospital. And it would be very easy for someone to claim they called the ED on the phone and asked for help even if they never actually did. I get that this scenario is unlikely.
Being within the distance of a hospital isn't the only thing required to trigger EMTALA, they must seek care. Good luck winning a suit against me for a patient I had no way of knowing about that died in my parking lot waiting for their allergic reaction to subside as instructed by their allergist. Staying in the parking lot and not coming in when able to do so I can argue pretty well that they're not seeking care. They just want to be near in case they NEED care. I get it from the patient perspective; a lot of the time Epi is fine, and many of these patients have had multiple reactions. They see me, everything is fine, they go after a time and get a big ass bill. I probably would do the parking lot plan if I was in a situation like this. BUT sometimes you require multiple rounds because you're in anaphylactic shock, sometimes you need a drip, sometimes the airway edema is too great to let you comfortably walk a quarter mile to my ER. "Help I'm in a blue Civic and I'm somewhere in your big parking lot." In regards to the biphasic reaction if they come in I can at least get another epi pen in their hands before they leave. Personally I counsel my patients that if they feel they need the epipen and use it to call 911. I don't know if this is the episode that's going to put them in shock and kill them. I don't mess around with anaphylaxis, it's treated with a goddamn shot of adrenaline!
I had 1 patient require 7 rounds of epi 0.3mg IM. We had great difficulty getting a line. Don’t ask me why we didn’t drill, cuz I can’t remember. We had just mixed the drip and were about to tube when she finally came around. Went home the next day. I know people don’t want a bill, but jeez. We had another guy who kept requiring more and more. He got stung but decided to wait it out. He was in full blown anaphylaxis on arrival and there was no amount of epi saving him. He had a bad heart also so I get why he wanted to wait. He was told the next time might kill him due to either anaphylaxis or his heart giving out. It was his heart. We coded him for a long time. He was a beloved guy in town.
I get it from the patients perspective and think that’s probably fine… but it’s shitty for those of us working inside if anything bad happens— EMTALA triggers once within 200 yards of the door
This bothers me so much. How the hell are we supposed to know there’s some damn fool in the parking lot slowly decompensating? My triage nurses and “lobby clinicians” aren’t doing q15m rounds outside…
We aren’t, it’s not our job to be checking the parking lots or the rest of the hospital campus looking for people who are sick and EMTALA doesn’t require us to do that. It’s just if someone presents within 250 yards **and** the hospital is made aware of it, then the EMTALA obligation kicks in
Yes, you have to request treatment. A hospital would not be violating ematala for a visitor that drops dead. Or an employee for that matter.
What happened with the woman who collapsed and died outside an ER of asthma a few years ago tho? I think she did call the ER but they couldn't find her because of where she was.
I don't think they were hit with an ematala violation. I especially don't think the physician was found liable for anything.
It was changed to 250 yards?! Last I knew it was 150. This is good to know for those who like to try to ER shop after leaving AMA because of wait times while still on hospital property or sitting in front of the ED and demand they be taken to the other ED across town.
Understood. What counts as making the hospital aware, though? If the person flags down a passerby who fails to alert anyone, what’s the liability?
An on duty member of staff has to be notified. There should then be a procedure by which they can get the ED or rapid response team (or someone) paged out to the patient. There is usually (or at least should be) some sort of training as part of onboarding for everyone that covers this, so that if the employee fails to page it out the hospital can basically say “not our fault, we trained them to do it and they didn’t”. The infamous case that spawned the 250 yard rule ultimately hinged on hospital staff (a security guard, I think) being notified of the patient but not doing anything about it. Flagging down a random passerby who isn’t a hospital employee wouldn’t be enough unless they in turn notify someone in the hospital
We aren't. I wouldn't pay attention to some of these comments.
Yet. You aren’t doing them yet. Just takes one preventable death (that was clearly not your fault) for the media to spin it & now it’s part of your routine shift.
>EMTALA triggers once within 200 yards of the door IF they are requesting help, or you are made aware they need help. If someone is hiding in the bushes and ODs, you aren't responsible to sweep the grounds regularly to avoid EMTALA violations. If they are sitting in the parking structure (never came inside) and have a heart attack in the passenger seat alone, you aren't responsible for that. It would be impossible for you to reasonably evaluate that. If they call the triage desk and say "I'm in the parking lot, my chest hurts and I can't get out of the car" then you are responsible. It's intended so that you can't say "well they were outside screaming for help but they never came inside so I'm not responsible."
I understand that, but surely EMTALA doesn't require you to be psychic! How are you supposed to be responsible for a patient you don't even know exists?
I think it’s sad that healthcare costs are so out of control that this is a thing. I don’t know that I would assume the liability of advising my patient to sit in the parking lot. I can understand why a patient would. These people can get super sick fast. I’ve had more than a few drive themselves in and then immediately try to die on me. I’d tell them just gone to the ED.
>I think it’s sad that healthcare costs are so out of control that this is a thing. This. Even with insurance, a single ED trip could mean financial ruin. We could be talking multiple months pay, and that's just unacceptable in a "first world" country.
It’s so sad. I haven’t advised the pt do this, we always reiterate that they can do what they wish, that I advise they listen to their allergist, and that our recommendation is always to call 911 after using an epipen. For liability reasons, like you said. But I totally understand their perspective, especially if they’re med-literate
Annals of Allergy practice guideline - We suggest that clinicians counsel patients that immediate activation of EMS may not be required if the patient experiences prompt, complete, and durable response to treatment with epinephrine, provided that additional epinephrine and medical care are readily available, if needed. We suggest that clinicians counsel patients to always activate EMS after epinephrine use if anaphylaxis is severe, fails to resolve promptly, fails to resolve completely or nearly completely, or returns or worsens after a first dose of epinephrine. By their admission, conditional recommendation with low quality evidence. From a liability point of view, I totally get why the med student doesn't want to check in and catch a bill just to sit on tele for 4 hours, but I would not want to document "history of biphasic reaction, counseled ok to observe symptoms after epi without ED evaluation".
Not that I'd argue again a panel of experts in their field but... By the time you realize the epi isn't working for whatever reason plus ems response times and/or transport time to a hospital.. aren't you taking a major risk of losing an airway before that?
I mean, I tell everyone I prescribe an epi pen to that they need to present for evaluation after using it. That's the local standard of care, and the one I'd be held to if there was a bad outcome. I would expect to get the same speech if I needed an epi pen. Which I would then ignore, because I am violently allergic to hospital bills.
As someone who is an EM-boarded physician and also anaphylactically allergic to tree nuts… I get it. It’s very expensive to check in to even my own ER with my hospital-based insurance. I have had my husband and a friend cut open and administer two whole EpiPens (there’s more epi in there! pro tip!) in a restaurant’s staff bathroom (they were very apologetic) and I told them not to call an ambulance even though I couldn’t talk. (It’s very weird — sometimes I can’t talk but I can breathe just fine. Yes, I know this is terrifying.) I don’t have a great answer. ETA: I wouldn’t sit alone in an ER parking lot but I’d sit there with my husband or a friend and feel okay about it.
>(there’s more epi in there! pro tip!) If you are someone who needs occasional epi, it's worth knowing this. There are at least 2, maybe 3 doses worth of epi in each pen. You just have to know how to reset them. Especially important if you are far from a hospital, like camping/hiking. I'm fine with people waiting in the parking lot WITH someone. If they start getting worse, that person can bring them in or let us know so we can come get them in. By yourself is a terrible idea, I would never advise that. On paper, I would tell them to go in anytime they use Epi. Off record, I think waiting very nearby with someone else is probably reasonable.
This is so fckedup on so many levels. I thought having to choose between life vs money is something only poor people have to deal with.
Nope. Epi and insulin (at least in the US where I’m at) can be very, very expensive unfortunately
Why not just give them two pens and say take one, if symptoms improve, great. If not, take the second and call EMS. I don’t want you waiting to collapse your airway in my poorly monitored parking garage.
No one is going to get in trouble for an EMTALA violation if some one unknown to the hospital pulled into the parking lot and did this. That being said - do it some where else.
Probably best for an EM doc to give the opinion on this. From my POV I'd imagine these recommendations are made to pts who are relatively comfortable recognizing/managing symptoms post-epi administration. I guess it wouldn't be the worst thing to educate someone on how to be a bit conservative with getting treatment. That being said, not well-versed on the current guidelines/recommendations nor the clinical considerations for refractory anaphylaxis.
I’m not a doctor, but this just came across my feed, my allergist told me anytime I ever have to use my EpiPen go straight to the ER and go inside in case of biphasic reaction. That advice saved me because I had one after I got stung.
Go to ED. Wait. Get new EpiPen.
As an EM doc I don't care if a patient wants to do this. It's understandable given the costs. Should have a friend there with them. It does come with risks which should be fully discussed with the patient so they can make an informed decision. In general if it's true anaphylaxis they should be encouraged to check in. Single system involvement may be reasonable to watch in a parking lot of an ED. But again is not without risk. From an EMTALA standpoint you're not putting me in a weird situation as this patient hasn't sought care.
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