By Alec Pruchnicki, MD
Arthur Schwartz’s harrowing account of his heart attack in last month’s issue of WestView accurately portrayed many aspects of what a patient goes through in the middle of an emergency situation. But there are a few unanswered questions that should be addressed so that people can understand some of the subtleties of hospital procedures.
Once the staff at Northwell (aka “The Healthplex”) had confirmed that Arthur was having a heart attack, they immediately arranged for him to go to the Catheterization Lab (Cath Lab) at Beth Israel. When he requested NYU instead, they refused. Why? Since its opening, Northwell has promised that patients who require hospitalization can go to the facility of their choice. But, there are several important modifications to this promise.
First, the patient must be stable. What is “stable?” The vital signs (heart rate, blood pressure, respiratory rate, and temperature) must be within a standard range, as determined by the physicians or EMS workers, or the patient can suffer sudden cardiac or respiratory arrest and death within minutes. The patient can’t be in the middle of an acute event, like a heart attack or stroke, which can also cause sudden death. For trauma cases, such as penetrating knife or bullet wounds, injuries sustained in an auto accident, or a fractured neck, immediate hospitalization at an appropriate facility is required.
Second, what is an “appropriate facility?” The receiving hospital must have at least the ability, or staff, to care for the emergency. A heart attack requires a cath lab with a surgical suite (operating room) as back-up. A fractured neck might require a neurosurgical team in the hospital, or on-call, within minutes. Sometimes, the team must be assembled, as the Beth Israel Cath Lab team was rounded up to do Arthur’s catheterization. Unless the cath lab is extremely busy, and working on one case after another, staff must be called in from other parts of the hospital or from home.
Third, can these criteria be waived at the patient’s request? No. Emergencies that require a response within minutes necessitate a well-oiled and experienced team that is familiar with all protocols and procedures. Any deviation might increase the chance of a mistake and a bad outcome, like an avoidable death. If the emergency isn’t acute, such as when the heart attack or stroke is already over, or the fracture is in the hip instead of the neck, then maybe a transfer to a hospital of choice would be acceptable if the patient were still stable.
Finally, what was this “arrangement” that Northwell had with Beth Israel? Is this some kind of mercenary financial deal or a medical necessity? I don’t know the exact relationship between these two institutions, but I can tell you that any ER-to-hospital transfer, sometimes even within the same hospital, can be complicated. Communication methods must be clearly defined, whether by medical record print-outs, faxes, or computer programs. If computerized, software at both institutions must have been established and tested previously, and not in the middle of a minute-by-minute emergency. If this relationship is not just a working arrangement between institutions that know each other, but is actually legally formalized, then the lawyers on both sides of the transfer would have scrutinized every detail of the collaboration beforehand.
It appears that Northwell did everything it promised and within accepted medical guidelines. Arthur is alive. It isn’t clear how many of these same services will be available when Beth Israel is downsized several years from now. But, under those circumstances, patients would go to Bellevue, ten blocks uptown. Let’s hope the results will be the same.