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Based on clinical and facility record reviews and staff interviews, the facility on call physician for vascular surgery failed to come to the hospital after a request for further evaluation and treatment of a patient in the Emergency Room (ER). The on-call vascular surgeon failed to provide consultation to the ER when requested by the ER attending physician who conducted the medical screening exam and identified the emergent medical condition for patient #5. Refer to Tag A 2404 deficient practices cited in this report.

Based on clinical record review policies and procedures, letters,and staff interviews the facility failed to provide further consultation by the vascular physician on call to the ER on March 02, 2010, when request for further evaluation and treatment was made by the physician who conducted the medical screening exam, and identified an emergent medical condition for 1 of 20 (#5) sampled patients.

The findings included:

Review of the current facility policy for EMTALA revealed that when a medical condition is found to exist through the physician medical screening exam, on call physicians must be part of the process. The on call list defines the physicians who respond for further evaluation and or Necessary treatment to stabilize an individual after the medical condition is identified. The services of the specialty physicians is documented on the on call list.


Review of the clinical record for patient #5, from the transferring hospital, revealed the patient presented to the transferring facility's ER on 3/02/10 at 11:10 AM after a fall in the rain while wearing slippers. The patient who weighs 300 pounds fell off a curb onto the left side of the body. Rescue transported the patient to the transferring hospital. The Medical Screening Exam found injuries to the right forehead, right shoulder, left elbow, and left knee. The initial exam of the patient's left knee disclosed: no hematoma, no instability or subluxation; good pedal pulse and grossly intact sensory.
Computerized Tomography (CT) Scan of the patient ' s head, without contrast, showed no evidence of brain injury, CT scan of C-Spine showed no acute fracture; CT to left upper extremity showed a distal humerus fracture and radial head dislocation. X-rays were taken of the patient ' s left knee, left elbow and right shoulder. The left arm had fractures of the humerus and elbow joint. The patient refused a cervical collar. The patient was sedated and the dislocated shoulder was reduced at the bedside and a sling and swathe was applied. The left knee was immobilized, a left elbow splint was applied. At 1:40 PM, per clinical notes, the left knee had no numbness or decreased sensation. At 1630 hours a note documented by the orthopedic physician states that the patient is unable to move the left foot and a decrease in sensation is noted. The physician identifies vascular compromise, and wrote a request to get vascular consult with Dr. R------ and continue transfer to trauma center. Dr. R------ was the on-call vascular surgeon at the transferring hospital. The transferring hospital's ER physician documented at 1624 hours there is a change in the patient ' s sensation in the left knee, and at 1651 hours Dr. R----- told them to transfer the patient to Lawnwood Regional Medical Center (LRMC). The on-call primary trauma surgeon at LRMC accepted the patient ' s transfer. LRMC was contacted at 5:00 PM for the transfer, and the patient left the transferring facility at 5:50 PM.

Review of the clinical record of patient #5 revealed that on arrival to LRMC (the receiving hospital) on 3/02/10 at 7:10 PM, patient #5 was assessed/examined, and the findings are documented in a history and physical by the primary trauma surgeon. The documentation includes the fractures and splinting, and it is also noted that the patient has diminished sensation in the lower extremities. Doppler exam of the lower extremities showed pulses in the right foot but none in the left. The patient had a CT angiogram of the left knee which did not show interruption of vascular flow. Dr. J------, the vascular physician on-call, was called for a vascular consult. The patient was noted to require monitoring and the plan was to admit to the trauma service in ICU. At the time of record review there was no supportive evidence confirming Dr. J--------'s response to the ER call for further vascular examination and treatment.
Clinical record review revealed, on 3/03/10 at 4:30 PM, Dr. J------- spoke with the patient and the spouse and explained that surgery was needed. Dr. J------ took the patient to surgery and completed a resection, graft and fasciotomy of the left knee vessels on 03/03/10 at 6:30 PM.

Review of the on-call schedule for March 2010 shows the medical director of the program, Dr J-------, was on-call for vascular surgery on 3/01/10, 3/02/10, and 3/03/10.

On 4/01/10 the medical director, Dr. J--------- delivered a letter to the CEO that stated, he had changed call with Dr. B------- on 03/02/10. The CEO stated that when Dr. B------- was asked, he knew nothing about changing call and had not been called into the ER to consult on the patient.

Interview on 12/1/10 at 12:45 PM with the medical director of the trauma program, Dr. J--------, confirmed that he was the one on call to the ER on 3/02/10 for vascular surgery, and also was on general, and trauma backup call. Dr. J-------- did not see patient #5 in the ER and refused to go to the facility when he was called on 03/02/10. Dr J------- asked for the vascular surgeon on call at the transferring hospital, Dr. R--------, who was in surgery at the receiving hospital, to see the patient. The following day, 3/03/10, when Dr. J-------- was called to evaluate the patient, he found that on the arteriogram the blood flow was completely occluded. He took the patient to the OR at 6:30 PM on 3/03/10, but stated the chance of survival of the graft and leg was diminished severely. The probability of success was 4% to 5% at best. The patient ' s knee wound was debrided several times over the next few days and Dr. J------- talked to the family about amputation. They refused initially, but relented later. After the amputation, the patient became septic and had multi-organ failure, and expired on 3/24/10.

Interview on 12/02/10 at 2:30 PM with Dr. B------- confirmed he had never requested to make any changes in the call schedule with Dr. J------- and was shocked and disappointed to hear that he would have to go to peer review for this. Dr. B------ is the primary trauma surgeon who was on duty on 3/03/10. Per Dr. B------, at 8:00 AM on 3/03/10 the trauma team had the daily meeting and discussed each patient on the trauma service at length. There were 12 patients that day. The meeting lasts from 1 to 2 hours depending on what information is required to be passed on to the takeover team. It was reported that " patient #5 had flow to the left leg. " Shortly thereafter, the oncoming team made rounds on all of the trauma service patients. At 9:30 AM, during the meeting, Dr. J--------- called the unit's charge nurse and ordered an ultrasound for patient #5. Dr. B------- stated that he saw patient #5 at about 11:00 AM on 03/03/10 and was unaware that Dr. J-------- had ordered an ultrasound. The patient was having the Doppler exam as he entered the patient ' s room. Dr. B------ ordered to repeat the Creatinine, which was 3.9 (norm up to 1.5). At 12 noon, Dr. B------ received the results of the Doppler exam, and found there was abnormal flow to the patient's left leg; the Creatinine was high; per Dr. B------, contrast used during an arteriogram could further compromise the kidney function. The radiologists generally will not use any contrast with the Creatinine at the level of 3.9. Dr. J------- was called as the vascular surgeon on call for the day 03/03/10 and given the results of the Doppler and the lab work. Dr. J------- ordered an arteriogram and apparently called the radiologist and managed to get the test ordered in spite of the Creatinine of 3.9. The arteriogram was begun at 3:45 PM. Dr. J------- was in surgery while this took place. Dr. J------- took patient #5 to surgery at 6:30 PM.

Interview on 12/2/10 at 10:20 AM with Dr. R------, by telephone, confirmed that he was on call at the transferring facility but was in elective surgery at Lawnwood Regional Medical Center when the transferring facility called him regarding patient #5. The physician said he called his partners in to see the patient, and the patient was transferred to Lawnwood. He stated that he did not say that he would take the patient. The ER physician, Dr. Bu---- called him in the OR and said that Dr. J------- called and said that ' you have to take the patient. ' He reminded Dr. Bu---- that he was not the vascular surgeon on call at Lawnwood and he had not arranged the transfer. Dr. J------- called next, and threatened that Dr. R------ must take the patient or he would lose his privileges.

Interview on 12/02/10 at 10:45 AM with Dr. Bu----, the ER physician, confirmed he conducted a medical screening exam of patient #5 at 7:10 PM on 3/02/10. The left leg had no pulses. He called Dr. J------- who was on call for vascular surgery. Dr. J------- was called to come in and examine the patient for vascular injuries and Dr. J------- refused to come to the ER. Dr. J------- told Dr. Bu---- to call Dr. R------, stating it was his patient. Dr. Bu---- called Dr. R------ who said he was not on call at Lawnwood for vascular surgery. Dr. Bu---- then called the primary trauma surgeon, Dr. D------ to evaluate the patient for trauma injuries. Dr. Bu---- stated he had wrote a complete progress note of the time line and conversations with the various physicians, including Dr. J------- and that document has since disappeared from the record.

Interview on 12/02/10 at 9:00 AM with Dr. D------ the trauma surgeon in charge on 3/02/10 revealed, Dr. Bu----, the ER physician, called him and reported that he had patient #5 with orthopedic and vascular injuries. He had called the vascular surgeon on call, Dr. J------- who said ' no it was not his patient ' . He had called Dr. R------ who said he was not the vascular surgeon on-call at Lawnwood, he was already on call at the transferring hospital. He called Dr. D------ and Dr. D------ ordered a CT Angiogram and said he would admit the patient to ICU and trauma service.

During the interviews with Dr. J-------, Dr. R------, Dr. Bu------, Dr. B---- and Dr. D------ on 12/01/10 and 12/02/10 all of the physicians stated that once discovering the injury to the knee, the patient had a 6 hour window for success with a repair of the artery and/or vein. After 6 hours the success rate is greatly reduced. Patient #5 went to surgery for the vascular repair more than 24 hours after the injury was discovered, spending the first 6 hours and 40 minutes at the transferring hospital, thus lessening the odds that the circulation to the area could be successfully restored. The delay, 6 hours and 40 minutes delay in care experienced first at the transferring hospital followed by 23 hour time elapse / delay at the receiving hospital, decreased the success rate of the surgical repair and the subsequent amputations and sepsis.

Interview with the CNO and the CEO on 12/01/10 at 10:00 AM revealed patient #5 was transferred from ----- ------- Medical Center to Lawnwood Regional Medical Center (LRMC) on 3/02/10, and was accepted as a trauma patient by the trauma surgeon on call. The patient arrived at LRMC ' s ER and was evaluated by the trauma surgeon and the ER physician. It was determined and the patient would require vascular surgery for a popliteal vein/artery repair. As a result of the patient ' s expiration, Dr. J-------, the on call physician, brought Dr. B------ and Dr. R--------, vascular surgeons, before the medical executive committee for peer review. When peer review accepted the explanation from the 2 vascular surgeons that neither one was on call for the ER for vascular surgery on 3/02/10, no other physicians were examined/reviewed. The CEO asked that the physician on call, Dr J------, be subject to peer review also, and sent a letter of request to the president of the Medical Executive Committee. Apparently the letter was forwarded to the office of the Inspector General of the State from an unknown source. The medical director, Dr J------, told the CEO that he was not on call on 3/02/10.

Review of the letter from the office of Dr. J-------- requesting pay for vascular coverage on call for March 2010 revealed that the number of days requested was 21 to include 03/02/10. Review of the call schedule for March 2010 showed Dr. J-------- on call 21 days, including 3/02/10. The physician was paid by accounts payable for the 21 days on call.
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The facility failed to ensure that their policy "Emergency Medical Treatment and Labor Act" . . ."On-Call List" was followed, on March 02, 2010 for patient #5. The facility failed to ensure that as stated in their policy "Physicians who are "on call" for duty after the initial MSE (Medical Screening Examination) to provide further evaluation and/or treatment necessary to stabilize an individual with an EMC (Emergency Medical Condition).