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Based on record review and interview the facility on call physician for vascular surgery refused to respond to provide further consultation to the ER when requested by the ER physician who conducted the medical screening exam and identified a change in the medical condition for patient #1; and caused a delay in care which decreased the success rate of the surgical repair and the subsequent amputations. Refer to Tags A2404, A2407, and A2409.

Based on review of medical records, policies and procedures, physician privileges, on-call schedules, medical staff by-Laws and Regulations & Regulations, and interviews the facility failed to provide further consultation by the vascular surgeon on call to the ER when requested by the ER physician who conducted the medical screening exam and identified the change in the medical condition for 1 of 20 (#1) patients.


The findings included:

Review of the privileges by individual provider for the vascular surgeon on call to the ER on 3/2/10 included the diagnosis and surgical treatment of vascular injuries in patients of all ages.

Review of the medical staff by-laws, rules and regulations revealed that the medical staff shall maintain an ER call schedule by specialty and physicians within the specialty are rotated on call for a 24 hour period. On call staff must respond to a call within 30 minutes and must attend to the needs of the patient within a reasonable time and appropriate to the patient ' s condition. The on call specialist with the assistance of the ER physician shall be responsible for the patients care and treatment until an appropriate disposition is made.

Review of current facility policy for patient screen and stabilization revealed that medical screening shall be conducted to determine whether the individual has an emergency medical condition; a medical condition with acute symptoms of sufficient severity that could result in serious dysfunction of any body part. A patient found to have an emergency medical condition shall be provided with stabilizing treatment. The facility maintains a list of physicians who are on call after the initial examination by the ER physician to provide the treatment necessary to stabilize an individual with an emergency medical condition. If the patient ' s condition remains unstable treatment shall continue to be provided. The patient may not be discharged, but may still be transferred within the guidelines of the facility policy for transfers to other hospitals or acute care facilities.

Review of the current facility policy for transfers to other hospitals or acute care facilities revealed that the guidelines are that the on call specialist may be consulted and required to come into the facility if deemed necessary by the ER physician.

Interview on 12/20/10 at 9:15 am with the director of medical staff services revealed that if there are partners to the physician taking ER call that will be covering for the scheduled physician; the office must be notified in writing. If there were an emergency that prevented the specialist from providing on call care to the ER, a call would be made to the ER that day and the schedule would be changed. Review of on call schedule for the emergency room (ER) for specialty physicians revealed that the vascular surgeon on call was on call to the Indian River Medical Center (IRMC) ER for 14 days in March 2010 which included 3/2/10. Review of the documentation provided by the medical staff office confirmed that the physician submitted a signed compensation attestation for the 14 dates of ER call, which included 3/2/10. The director of medical staff services confirmed that neither vascular surgeon has a partner in his practice. They practice alone.

While reviewing the complaint at the Acute Care Hospital /Trauma Center (ACH/TC - Patient #1 was transferred to this hospital ) on 12/2/10 the Vascular surgeon was interviewed by telephone. Interview on 12/2/10 at 10:20 am with the vascular surgeon confirmed that he was on call at IRMC but was in elective surgery at the ACH/TC when IRMC called him regarding a patient (IRMC patient #1). The physician called his partners in to see the patient and the patient was transferred to the ACH/TC. He stated that he did not say that he would take the patient at the ACH/TC. He reminded the ER physician at the ACH/TC that he was not the vascular surgeon on call at the ACH/TC and he had not arranged the transfer for patient #1.

Interview and clinical record review on 12/20/10 at 10 am with the Director of Emergency and Diagnostic Imaging Services revealed that patient #1 fell outdoors in the rain in the vicinity of her home on 3/2/10. 911 was called and the patient was transported to IRMC by county rescue. The rescue documentation revealed that the patient was found on the ground, in the rain with contusions on the face and forehead, acute pain the right shoulder, contusions on the left knee and left elbow. The blood pressure was 170/100. The ER physician examination was at 11:03 am in the treatment area. The patient reported that she fell and struck her head, had a headache with no loss of consciousness, no amnesia, a sharp pain in the right shoulder, left elbow and left knee. The patient could not bear weight to walk. There were palpable pedal pulses and no extremity edema. The ER physician ordered CT scans and x-rays and called the orthopedic physician on call in to see the patient. The CT cervical spine showed no fracture; the CT of the head showed no fracture or hemorrhage; CT of the elbow showed the distal humerus fracture and the fracture and radial head dislocation; the right shoulder x-ray showed an acute dislocation; the left elbow x-ray showed possible distal humerus fracture; the left knee x-ray showed acute posterior dislocation of the tibia on the femur and an acute dislocation of the left knee and possible tibial plateau fracture; proximal fibular fracture. At 1:05 pm the patient gave consent for sedation and the ER physician reduced and realigned the dislocated right shoulder; the left knee was relocated in line with a stabilizer. A Velcro knee immobilizer was used. After the procedure, the ER physician documented that the distal pulses were intact in all 4 extremities. At 3 pm the orthopedic physician on call came in to evaluate the patient. After the evaluation, he spoke with 2 of his partners and they decided to transfer the patient to the trauma center because she met the fracture criteria with every fracture documented on x-ray. The patient agreed to the transfer. The trauma center at the ACH/TC agreed to take the patient. There was physician to physician acceptance and nurse to nurse report to the trauma center at the ACH/TC. As the transfer to the trauma center was being arranged, the orthopedic and the ER physicians were at the bedside and found the decreased movement and palpable pulse in the patients left foot. The vascular surgeon on call was called for an evaluation of the left knee injury. The documentation by the ER physician revealed that the vascular surgeon on call was reached by phone and wanted the patient transferred to the ACH/TC as planned. The ER physician described the possibility of a vascular injury and the vascular surgeon on call said to just send the patient and that he would likely consult on the patient at the trauma center. Review of the orthopedic consultation dictated by the on call orthopedic surgeon on 3/2/10 at 4:35 pm revealed that patient #1 stated that she noted that there was numbness in the left foot since the injury. All of the extremities were tender to palpation with some swelling. On examination there was no motor function or sensory distal to the left ankle. The ER physician recalled the vascular surgeon on call and reiterated the time from the injury to the time of decreased pulses and sensation in the left leg. The vascular surgeon on call was asked to come in to evaluate the patient and again the vascular surgeon on call said to just transfer to the trauma center ACH/TC. Review of the case management notes in the clinical record revealed that the patient was scheduled for a trauma transfer when the vascular injury was identified. The on call vascular surgeon was called and decided the patient was ok to transport and would see the patient in the ACH/TC.

Interview on 12/20/10 at 11 am with the Director of Patient Safety and Quality Management confirmed that the vascular surgeon on call had no partners in his practice. He was called and responded to the ER physician and the on call orthopedic surgeon. He refused to come in to see patient #1. He said to transfer the patient and he would see the patient at the ACH/TC. He talked about the risk of vascular injury but provided no vascular evaluation at IRMC. The ER staff had the best of intentions to send the patient to the vascular surgeon on call for evaluation. They never expected that he would then refuse to see the patient.

Interview on 12/20/10 at 11:15 am with the director of emergency and diagnostic imaging services revealed that the orthopedic surgeon on call identified in a dictated consult the need for treatment of a vascular injury. He called his partners to verify the vascular injury and immobilized the knee fracture. The vascular surgeon on call was called to report the orthopedic trauma with possible vascular injury. The orthopedic surgeons agreed that this was a trauma patient and with vascular injury. The need for care was serious. The vascular surgeon on call responded that he was already at the ACH/TC and stated that he would likely consult on the patient in the trauma center.

Interview on 12/20/10 at 11:30 am with the Medical Director of the ER revealed that patient #1 had multiple joint injuries. The left knee was potentially complicated with an orthopedic/vascular combination injury. There is a narrow window of time for successful repair of vessels. The orthopedic surgeon wanted the patient transferred to the trauma center. When the on call vascular surgeon was called, he refused to come in as he was in the operating room at the ACH/TC. The ER physician spoke with the vascular surgeon and orthopedics twice to confirm the transfer and assessment at the ACH/TC of the vascular injuries. The medical director stated that if the vascular surgeon on call had refused outright to come, the other vascular surgeon would have been called; but that is not what happened. The vascular surgeon on call stated that he would see the patient in the trauma center(ACH/TC). The patient had been stabilized orthopedically, but was unstable from a vascular point and should have had vascular surgery at IRMC. The vascular surgeon on call insisted on the transfer and the patient went to the ACH/TC.

Interview on 12/20/10 at 12:30 pm with the Chief of the Medical Staff and the only other vascular surgeon on staff at IRMC revealed that a surgeon can be on call at IRMC and in elective surgery at another facility if he can be reached by phone within 30 minutes. There is no specific rule that does not allow this. However, this will probably change when the medical executive committee updates the by-laws, rules and regulations. The chief of the medical staff stated that he did not assess or treat patient #1 but, with any dislocation a nerve injury can happen. There was no detectable blood flow and a call went out to the vascular surgeon on call. There is a narrow window of time for successful repair of vessels. The patient transfer should have been stopped and vascular assessment should have been done. The vascular surgeon on call exerted pressure to transport the patient to him at the ACH/TC and when the patent got to the trauma center, the vascular surgeon on call was at home stating that he was not on call at the ACH/TC. He did not come in to assess the vascular injury at either facility. A multidisciplinary review was conducted and reported to the chairman of the board at IRMC. At the meeting the review team was critical of the management of the case of patient #1. The patient should have been stabilized before transfer. The vascular surgeon on call justified the transfer by stating that the patient needed the orthopedic and vascular trauma care and IRMC orthopedic surgeons could not manage the case where the trauma center could.

The on call orthopedic surgeon was out on leave from a bicycle accident and was unable to be reached by phone. His practice partner was interviewed by telephone on 12/20/10 at 12:45 pm. The on call orthopedic surgeon had examined all of the long bone fractures of patient #1 and had consulted 2 of the partners regarding management of the patient. The decision was that every long bone was fractured and the patient would require treatment by trauma surgeons and should be transferred. With the additional possibility of a vascular injury to the knee vessels, the vascular surgeon on call to the ER was called.

Interview on 12/20/10 at 1:00 pm with the Chief Operating Officer revealed that the vascular surgeon on call did not come to IRMC to evaluate the patient. He did not outright refuse, but he made the ER staff believe that patient #1 would be seen sooner and managed better if she were sent to the ACH/TC. When patient #1 arrived at the trauma center, the vascular surgeon on call was at home stating to the trauma center that he was not on call. The IRMC staff did not intentionally send an unstable patient; when they started the transfer process the patient only had orthopedic injuries. The vascular surgeon on call was called when the lack of circulation was discovered by examination of the ER physician and the orthopedic surgeon on call.

Interview and review on 12/20/10 at 1:15 pm with the Director of Emergency and Diagnostic Imaging Services revealed that the current facility policy for the criteria for documenting trauma for the purpose of transfer of the patient is that 2 or more long bones be fractured. The long bones includes the humerus, radius, ulna, femur, tibia or fibula, the systolic blood pressure over 90, age 55 or over, etc. Patient #1 had documented fractures of all the long bones on the criteria list and met the criteria for transfer to the trauma center. The ER physician repaired, reduced, strapped and stabilized all of the fractures for transfer. When the ER physician and the orthopedic surgeon went to the bedside of the patient, they discovered through interview and examination that there was a vascular injury and called the on call vascular surgeon.

Interview on 12/21/10 at 9:20 am, by telephone, with the ER physician who treated patient #1 revealed that the patient reported to the orthopedic surgeon at 4:30 pm that her left foot had been numb since the fall. The pedal pulses were heard until that interview. The patient had not told any other staff about the numbness. The ER physician spoke with the vascular surgeon on call. The vascular surgeon on call said to send the patient to the ACH/TC because he was in surgery there. The vascular surgeon on call did not outright refuse to come, but did not come into the ER at IRMC to provide further assessment and evaluation of the patient. The vascular surgeon on call insisted that the patient be sent to him at the ACH/TC to be seen. A second call was placed to the vascular surgeon on call by the ER physician to make sure that he was not coming in to see the patient since there was a probable injury to the vessels. The vascular surgeon on call kept saying send the patient. The vascular surgeon on call insisted that he was there and would see the patient.

Interview on 12/21/10 at 11:15 am with the chief medical officer revealed that EMTALA training is provided to all physicians as they come on board staff. The general staff and employed physicians complete risk management updates annually which includes EMTALA training.

Interview on 12/21/10 at 11:45 am with the vascular surgeon on call on 3/2/2010 revealed that the ER physician called him while he was in the operating room (OR) at the ACH/TC to say that patient #1 had orthopedic injuries that warranted transfer to the trauma center. Orthopedics had discovered a probable vascular injury and called him to ask what tests needed to be done before transfer. The transfer was already planned. If the vascular surgeon on call had come into IRMC and taken the patient to the OR, he would have had to shop around for orthopedic surgeons, because the surgeon on call was not capable of managing the injuries the patient already had. The vascular surgeon on call stated that he was not called to come in, but rather to ask what he would suggest before transfer. The trauma center had already accepted the patient. The vascular surgeon on call does not think that the patient was unstable, but had done no evaluation or assessment of the patient in order to make this determination. Patient #1 was injured at approximately 10:00 am and was admitted to the IRMC ER and examined by the ER physician at 11:00 am. The patient later stated that she had numbness in the left lower extremity since the fall. The assessments done at IRMC identified that pedal pulses were present until 4:30 pm. The patient did not have a vascular evaluation once the probability of the injury was identified. The on call vascular surgeon failed to assess and evaluate the injury at IRMC. He stated that since the trauma transfer was already in progress, why stop it; just send the patient. The unstable patient was transferred at 5:50 pm. The vascular surgeon refused to see the patient once she was in the trauma center because he was not on call there that day. The delay in the care to the injury decreased the success of the surgical repair for patient on 3/2/2010.

While reviewing the complaint at the ACH/TC on 12/2/10 it was revealed by 5 physicians at the ACH/TC 3 vascular surgeons, 1 ER physician, and 1 trauma surgeon, that once discovering the injury to the knee, the patient had a 6 hour window for success with a repair of the vessels. After 6 hours the success rate is greatly reduced. Patient #1 went to surgery for the vascular repair more than 24 hours after the injury was discovered, thus lessening the odds that the circulation to the area could be successfully restored. The delay in care decreased the success rate of the surgical repair and the subsequent amputations. During interviews on 12/21/10 at IRMC, 3 physicians at IRMC; the medical director ER, the chief of medical staff and vascular surgeon and again with the vascular surgeon on call and they agreed that a very short window exists for repair to vascular injuries of the knee vessels.

Based on reviews of medical records, physician privileges, on -call schedules, policies and procedures, medical staff by-laws and rules and regulations and interviews the facility failed to provide stabilizing treatment by the vascular surgeon on call to the ER when requested by the ER physician who conducted the medical screening exam and identified a change in the medical condition for 1 of 20 (#1) patients.


The findings included:

Review of the privileges by individual provider for the vascular surgeon on call to the ER on 3/2/10 included the diagnosis and surgical treatment of vascular injuries in patients of all ages.

Review of the medical staff by-laws, rules and regulations revealed that the medical staff shall maintain an ER call schedule by specialty and physicians within the specialty are rotated on call for a 24 hour period. On call staff must respond to a call within 30 minutes and must attend to the needs of the patient within a reasonable time and appropriate to the patient ' s condition. The on call specialist with the assistance of the ER physician shall be responsible for the patients care and treatment until an appropriate disposition is made.

Review of current facility policy for patient screen and stabilization revealed that medical screening shall be conducted to determine whether the individual has an emergency medical condition; a medical condition with acute symptoms of sufficient severity that could result in serious dysfunction of any body part. A patient found to have an emergency medical condition shall be provided with stabilizing treatment. The facility maintains a list of physicians who are on call after the initial examination by the ER physician to provide the treatment necessary to stabilize an individual with an emergency medical condition. If the patient ' s condition remains unstable treatment shall continue to be provided.

Interview on 12/20/10 at 9:15 am with the director of medical staff services revealed that if there are partners to the physician taking ER call that will be covering for the scheduled physician; the office must be notified in writing. If there were an emergency that prevented the specialist from providing on call care to the ER, a call would be made to the ER that day and the schedule would be changed. Review of on call schedule for the emergency room (ER) for specialty physicians revealed that the vascular surgeon on call was on call to the Indian River Medical Center (IRMC) ER for 14 days in March 2010 which included 3/2/10. Review of the documentation provided by the medical staff office confirmed that the physician submitted a signed compensation attestation for the 14 dates of ER call, which included 3/2/10. The director of medical staff services confirmed that neither vascular surgeon has a partner in his practice. They practice alone.

While reviewing the complaint at the ACH/TC on 12/2/10 the vascular surgeon was interviewed by telephone. Interview on 12/2/10 at 10:20 am with the vascular surgeon confirmed that he was on call at IRMC but was in elective surgery at the Acute Care Hospital/Trauma Center (ACH/TC) when IRMC called him regarding a patient. (IRMC patient #1) The physician called his partners in to see the patient and the patient was transferred to the ACH/TC. He stated that he did not say that he would take the patient at the ACH/TC. He reminded the ER physician at the ACH/TC that he was not the vascular surgeon on call and he had not arranged the transfer.

Interview and clinical record review on 12/20/10 at 10 am with the director of emergency and diagnostic imaging services revealed that patient #1 fell outdoors in the rain in the vicinity of home on 3/2/10. 911 was called and the patient was transported to IRMC by county rescue. The rescue documentation revealed that the patient was found on the ground, in the rain with contusions on the face and forehead, acute pain the right shoulder, contusions on the left knee and left elbow. The blood pressure was 170/100. The ER physician examination was at 11:03 am in the treatment area. The patient reported that she fell and struck her head, had a headache with no loss of consciousness, no amnesia, a sharp pain in the right shoulder, left elbow and left knee. The patient could not bear weight to walk. There were palpable pedal pulses and no extremity edema. The ER physician ordered CT scans and x-rays and called the orthopedic physician on call in to see the patient. The CT cervical spine showed no fracture; the CT of the head showed no fracture or hemorrhage; CT of the elbow showed the distal humerus fracture and the fracture and radial head dislocation; the right shoulder x-ray showed an acute dislocation; the left elbow x-ray showed possible distal humerus fracture; the left knee x-ray showed acute posterior dislocation of the tibia on the femur and an acute dislocation of the left knee and possible tibial plateau fracture; proximal fibular fracture. At 1:05 pm the patient gave consent for sedation and the ER physician reduced and realigned the dislocated right shoulder; the left knee was relocated in line with a stabilizer. A Velcro knee immobilizer was used. After the procedure, the ER physician documented that he distal pulses were intact in all 4 extremities. At 3 pm the orthopedic physician on call came in to evaluate the patient. After the evaluation, he spoke with 2 of his partners and they decided to transfer the patient to the trauma center because she met the fracture criteria with every fracture documented on x-ray. The patient agreed to the transfer. The ACH/TC agreed to take the patient. There was physician to physician acceptance and nurse to nurse report to the trauma center at the ACH/TC. As the transfer to the trauma center was being arranged, the orthopedic and the ER physicians were at the bedside and found the decreased movement and palpable pulse in the patients left foot. The vascular surgeon on call was called for an evaluation of the left knee injury. The documentation by the ER physician revealed that the vascular surgeon on call was reached by phone and wanted the patient transferred to the ACH/TC as planned. The ER physician described the possibility of a vascular injury and the vascular surgeon on call said to just send the patient and that he would likely consult on the patient at the trauma center. Review of the orthopedic consultation dictated by the on call orthopedic surgeon on 3/2/10 at 4:35 pm revealed that patient #1 stated that she noted that there was numbness in the left foot since the injury. All of the extremities were tender to palpation with some swelling. On examination there was no motor function or sensory distal to the left ankle. The ER physician recalled the vascular surgeon on call and reiterated the time from the injury to the time of decreased pulses and sensation in the left leg. The vascular surgeon on call was asked to come in to evaluate the patient and again the vascular surgeon on call said to just transfer to the trauma center. Review of the case management notes in the clinical record revealed that the patient was scheduled for a trauma transfer when the vascular injury was identified. The on call vascular surgeon was called and decided the patient was ok to transport and would see the patient in the trauma center (ACH/TC).

Interview on 12/20/10 at 11:30 am with the Medical Director of the ER revealed that patient #1 had multiple joint injuries. The left knee was potentially complicated with an orthopedic/vascular combination injury. There is a narrow window of time for successful repair of vessels. The orthopedic surgeon wanted the patient transferred to the trauma center. When the on call vascular surgeon was called, he refused to come in as he was in the operating room at the ACH/TC. The ER physician spoke with the vascular surgeon and orthopedics twice to confirm the transfer and assessment at the ACH/TC of the vascular injuries. The medical director stated that if the vascular surgeon on call had refused outright to come, the other vascular surgeon would have been called; but that is not what happened. The vascular surgeon on call stated that he would see the patient in the trauma center. The patient had been stabilized orthopedically, but was unstable from a vascular point and should have had vascular surgery at IRMC. The vascular surgeon on call insisted on the transfer and the patient went to the trauma center.

Interview on 12/20/10 at 12:30 pm with the Chief of the Medical Staff and the only other vascular surgeon on staff at IRMC revealed that a surgeon can be on call at IRMC and in elective surgery at another facility if he can be reached by phone within 30 minutes. The Chief of the Medical Staff stated that he did not assess or treat patient #1 but, with any dislocation a nerve injury can happen. There was no detectable blood flow and a call went out to the vascular surgeon on call. There is a narrow window of time for successful repair of vessels. The patient transfer should have been stopped and vascular assessment should have been done. The vascular surgeon on call exerted pressure to transport the patient to him at the ACH/TC and when the patent got to the trauma center, the vascular surgeon on call was at home stating that he was not on call at the ACH/TC. He did not come in to assess the vascular injury at either facility. A multidisciplinary review was conducted and reported to the chairman of the board at IRMC. At the meeting the review team was critical of the management of the case of patient #1. The patient should have been stabilized before transfer. The facility failed toensure that further medical examination and treatment as required to stabilize patient #1's vascular emergency medical condition was provided on March 2, 2010.

Interview on 12/20/10 at 1:00 pm with the Chief Operating Officer revealed that the vascular surgeon on call did not come to IRMC to evaluate the patient. He did not outright refuse, but he made the ER staff believe that patient #1 would be seen sooner and managed better if she were sent to the ACH/TC. When patient #1 arrived at the trauma center, the vascular surgeon on call was at home stating to the trauma center that he was not on call. The IRMC staff did not intentionally send an unstable patient; when they started the transfer process the patient only had orthopedic injuries. The vascular surgeon on call was called when the lack of circulation was discovered by examination of the ER physician and the orthopedic surgeon on call.

Interview and review on 12/20/10 at 1:15 pm with the Director of Emergency and Diagnostic Imaging Services revealed that, when the ER physician and the orthopedic surgeon went to the bedside of the patient, they discovered through interview and examination that there was a vascular injury and called the on call vascular surgeon.

While reviewing the complaint at the ACH/TC on 12/2/10 it was revealed by 5 physicians at the ACH/TC 3 vascular surgeons, 1 ER physician, and 1 trauma surgeon that once discovering the injury to the knee, the patient had a 6 hour window for success with a repair of the vessels. After 6 hours the success rate is greatly reduced. Patient #1 went to surgery for the vascular repair more than 24 hours after the injury was discovered, thus lessening the odds that the circulation to the area could be successfully restored. The delay in care decreased the success rate of the surgical repair and the subsequent amputations and sepsis. During interviews on 12/21/10 at IRMC, 3 physicians at IRMC; the Medical Director ER, the chief of medical staff and vascular surgeon and again with the vascular surgeon on call and they agreed that a very short window exists for repair to vascular injuries of the knee vessels.

Patient #1 was injured at approximately 10:00 am and was admitted to the IRMC ER and examined by the ER physician at 11:00 am. The patient later stated that she had numbness in the left lower extremity since the fall. The assessments done at IRMC identified that pedal pulses were present until 4:30 pm. The patient did not have a vascular evaluation once the probability of the injury was identified. The on call vascular surgeon failed to assess, evaluate and stabilize the injury at IRMC. He stated that since the trauma transfer was already in progress, why stop it; just send the patient. The unstable patient (#1) was transferred at 5:50 pm. to the ACH/TC on March 2, 2010.

Based on reviews of medical records, policies and procedures and interviews the facility failed to provide an appropriate transfer by not providing vascular medical treatment that was within its capacity to minimize the health risks and transferred an unstable patient to a facility where the same level of care for 1 of 20 (#1) patients and transferred an unstable patient.


The findings included:

Review of the current facility policy for transfers to other hospitals or acute care facilities revealed that the guidelines are that the on call specialist may be consulted and required to come into the facility if deemed necessary by the ER physician.

An interview was conducted on 12/20/10 at 10 am with the Director of Emergency and Diagnostic Imaging Services. The interview revealed the vascular surgeon on call was called for an evaluation of the left knee injury. The documentation by the ER physician revealed that the vascular surgeon on call was reached by phone and wanted the patient transferred to the ACH/TC as planned. The ER physician described the possibility of a vascular injury and the vascular surgeon on call said to just send the patient and that he would likely consult on the patient at the trauma center. Review of the orthopedic consultation dictated by the on call orthopedic surgeon on 3/2/10 at 4:35 pm revealed that patient #1 stated that she noted that there was numbness in the left foot since the injury. All of the extremities were tender to palpation with some swelling. On examination there was no motor function or sensory distal to the left ankle. The ER physician recalled the vascular surgeon on call and reiterated the time from the injury to the time of decreased pulses and sensation in the left leg. The vascular surgeon on call was asked to come in to evaluate the patient and again the vascular surgeon on call said to just transfer to the trauma center. Review of the case management notes in the clinical record revealed that the patient was scheduled for a trauma transfer when the vascular injury was identified. The on call vascular surgeon was called and decided the patient was ok to transport and would see the patient in the trauma center.

Interview on 12/20/10 at 11:30 am with the Medical Director of the ER revealed that patient #1 had multiple joint injuries. The left knee was potentially complicated with an orthopedic/vascular combination injury. There is a narrow window of time for successful repair of vessels. The orthopedic surgeon wanted the patient transferred to the trauma center. When the on call vascular surgeon was called, he refused to come in as he was in the operating room at the ACH/TC. The ER physician spoke with the vascular surgeon and orthopedics twice to confirm the transfer and assessment at the ACH/TC of the vascular injuries. The medical director stated that if the vascular surgeon on call had refused outright to come, the other vascular surgeon would have been called; but that is not what happened. The vascular surgeon on call stated that he would see the patient in the trauma center. The patient had been stabilized orthopedically, but was unstable from a vascular point and should have had vascular surgery at IRMC. The vascular surgeon on call insisted on the transfer and the patient went to the trauma center. The facility failed to provide an appropriate transfer by not providing vascular medical treatment within its capacity to minimize the health and risk, and transferring patient #1 on 3/2/2010, an unstable patient to a facility with the same level of care.