The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on interviews, review of medical records, Medical Staff Rules and Regulations, DCH Regional Medical Center's General Surgery On Call Physicians' Schedule, and EMTALA policies and procedures, the hospital failed to:

A. Ensure the general surgeon on call for trauma services presented to the ED (Emergency Department) after a request was made by the ED physician, to evaluate PI # 6, a patient who arrived at the ED with gunshot wounds to the flank and needed further evaluation and possible surgical intervention to stabilize the patient's emergency medical condition (EMC) as determined by the ED physician. This affected one of 25 Emergency Department patient medical records reviewed.

B. Have a back up plan in place to address situations when the on call surgeon is unavailable to report to the ED due to scheduling and performing elective surgery at the same time the surgeon is designated as the on call surgeon for trauma and/or the on-call surgeon refuses to come to the ED at the request of the ED Physician to provide a surgical consultation for a patient with an emergency medical condition in need of further stabilizing treatment.

This deficient practice affected 1 of 25 sampled patient records reviewed and had the potential to negatively effect all patients that presented to this facility's emergency department.

Refer to Findings at A2404.

Based on review of the facility's Medical Staff Rules and Regulations, EMTALA (Emergency Medical Treatment and Labor Act) Policies and Procedures, General Surgery On Call Physicians' Schedule, Surgery Schedule for the On-Call Surgeon, Trauma Alert Log Sheet, Emergency/Trauma Services Trauma Alert Protocol - Division of Nursing, medical record reviews and interviews, it was determined the facility failed to:

A. Ensure the General Surgeon (Employee Identifier (EI) # 1) on call for trauma services, presented to the Emergency Department (ED) as requested by the ED Physician (EI # 5) on 12/27/13, to further evaluate Patient Identifier (PI) # 6, a patient with gunshot wounds (GSW) to the flank and was determined to have an emergency medical condition (EMC) by the ED physician as required by the Medical Staff Rules and Regulations.

B. Have a back up plan to address situations when the on call surgeon (physician) is unavailable to report to the ED due to scheduling and performing elective surgery at the same time the surgeon is designated as the on call surgeon for trauma and/or the on-call surgeon refuses to come to the ED at the request of the ED Physician to provide a surgical consultation for a patient with an emergency medical condition in need of further stabilizing treatment.

This deficient practice affected PI # 6, one of twenty-five sampled ED patient records reviewed, and has the potential to negatively affect all unattached patients who present to the ED and require a surgical evaluation by the on-call general surgeon for trauma services.

Findings include:

A). Medical Staff Rules and Regulations:

A review of the Medical Staff Rules and Regulations of DCH Regional Medical Center, revised and approved by the Governing Board on 6/25/13 included:

-"Section One: Scheduling Surgery."
..."An emergency case takes precedence over elective surgical cases not in progress..."

" Section 3: Emergency Department Assignment and Care of Service Patients:

(a) Emergency call lists shall be posted daily and it shall be the responsibility of the on-call physician to be available when needed. It is the responsibility of the physician listed that he either appears for duty or that he informs the appropriate hospital personnel of substitutions, otherwise, he remains responsible for call. When an on-call physician is contacted by the Emergency Department and requested to respond, the on-call physician must respond as follows: (a) by phone within 15-30 minutes, (b) in person, no longer than 30 minutes after telephone contact.

The Emergency Department physician, in consultation with the on-call physician, will determine whether the patient's condition requires the on-call physician to see the patient as soon as possible pursuant to applicable EMTALA (Emergency Medical Treatment and Active Labor Act) regulations."

B). DCH Regional Medical Center Emergency Department "Statement on EMTALA Emergency Medical and Active Labor Act" (Verified by hospital staff to be all of the Medical Center's EMTALA Policies and Procedures):

A review of the ... Emergency Department Statement on "EMTALA" policy included, "Stabilizing Treatment: If an EMC (Emergency Medical Condition) is found to exist, the hospital must stabilize the patient before he/she is discharged or transferred, subject to the following: ... must maintain a list of physicians who are on call for duty after the initial examination to provide treatment necessary to stabilize an individual with an EMC.

C). Surgery On-Call Schedule for December 2013:

A review of the hospital's on-call schedule dated December 2013 for "Surg. Surgery, General" revealed Employee Identifier (EI) # 1, was the General Surgeon On-Call on December 27, 2013 when PI # 6 presented to the ED.

D). Surgery Schedule dated 12/27/13 for the General Surgeon (EI # 1) on call:

A review of the surgery schedule dated 12/27/13 revealed EI # 1 (the on call surgeon) was involved in Surgical Case A the first time the ED Physician requested his presence in the ED to evaluate PI # 6. The surgeon (EI # 1) started Surgical Case B without presenting to the ED to evaluate PI # 6.

Surgical Case A: Surgeon's start time: 13:40. Surgeon's end time: 1522.

Surgical Case B: Surgeon's start time: 15:24. Surgeon's end time: 16:19.

E). Trauma Alert Log Sheet (Maintained in the ED):

A review of the Trauma Alert Log Sheet dated 12/27/13, revealed PI # 6 was designated as a Level One trauma patient (indicates hospital capable of providing total care for every aspect of PI # 6's injuries) on 12/27/13.

Type of Trauma: GSW (gunshot wound) to back.

T.S. (Trauma Surgeon) Name and Time Notified: Last name of EI # 1 at 14:12.

Time T.S. Returned Call: 14:16

Time T.S. Arrived to ED: No documentation.

F). A review of the Division of Nursing: Emergency/Trauma Services
Trauma Alert Protocol revealed:

I. Policy and Purpose:
It is recommended that the ED initiate the Trauma Alert Protocols upon notification of transfer of a major trauma patient to DCH Regional Medical Center...

II. Activation of Protocols:
In an effort to provide early, consistent notification of the Trauma Team that a major trauma patient is being transported to ...DCH Regional Medical Center, the ED Physician or RN (Registered Nurse)at Medical Control (with the ED Physician's knowledge) will activate the Trauma Alert System...

IV. Identification of the Trauma Patient:
The following guidelines will be used...for determining the classification of the trauma patient.

Class I: Critical, Life and Limb Threatening Injuries:
...Respiratory distress...rate less than 10 or greater than 29.
- Penetrating injuries to the neck, abdomen or thorax...
- Hemodynamically unstable vital signs...
- Penetrating or blunt head injury associated with coma or deteriorating LOC (level of consciousness)...

V. Pre-Hospital Care:
The ED Physician (EDP) will serve as Medical Control for the transport of all major trauma patients to DCH Regional Medical Center.

VI. Prior to Patient Arrival:
Upon notification of transport of a major trauma patient to the ED, the Trauma Alert Protocol will be initiated as deemed appropriate by the EDP. Trauma Team members will assume responsibility including, but not limited to the following:

A. Emergency Department Physician:

1. Communicates to the RN assisting at Medical Control that the Trauma Alert Protocols should be initiated. The following information is provided:
- Estimated time of Arrival (ETA)
- Mechanism and type of traumatic injury
- Single or Multiple systems trauma...

2. Notifies or will assure notification of the following:
- Trauma Surgeon and/or Neurosurgeon
- Anesthesiologist
- Radiologist when appropriate

B. Trauma Surgeon Coverage
1. The Trauma Surgeon should be in the ED at the time of arrival for all Class I patients, when given appropriate notice. The Trauma Surgeon should arrive promptly if the patient arrives unannounced or the ETA (estimated time of arrival) is less then 15 minutes...

G. Review of PI # 6's ED Medical Record dated 12/27/13 included the following:

Time Seen by Provider (ED Physician): 1508...

History of Present Illness: 24 y/o (year old) male presents to ED for evaluation and stabilization of two GSWs (gun shot wounds) via EMS (Emergency Medical Services)... was shot at least one time and thought to be shot twice in the left flank. EMS reports he initially was AAO (awake, alert, oriented) and just PTA (prior to arrival) became unconscious and went into respiratory arrest. On arrival EMS using bag mask ventilation.

Location: left lower flank

Duration: prior to arrival

Onset/Timing: sudden onset, still present

Quality: severe

Physical Examination:
General: The triage notes have been reviewed. Vital signs have been reviewed. The patient is "inresponsive" (unresponsive).

A (Airway), B (Breathing), C (Circulation), D (Disability/ Neurological Evaluation)

Bag mask ventilation is in progress, no spontaneous resp (respiratory) effort

Heart rate 120 and blood pressure 40 by doppler (ultrasound measures blood flow and pressure in blood vessels).

Pupils fixed and dilated.

GCS: (Glasgow Coma Scale - Objective method of recording conscious state of a patient) is 5.

Skin: Cold and calmly (clammy), pale.

Head: Atraumatic.

Eyes/ENT (Ears, nose and throat): Ears and nose reveal a normal inspection. Pharynx is normal.

Neck: Cervical without palpable deformity.

Trachea is midline.

No JVD (Jugular Venous Distention).

Back: One GSW(gunshot wound) entrance wound left lower lateral flank on inspection.

No step-off (no obvious, palpable deformities) upper thoracic spine.

No step-off upper lumbar spine.

No CVA tenderness.

Respiratory: No respiratory effort.

Chest: No crepitus or deformity or obvious injury.

Cardiac: Asystole.

GI/Abdomen (Gastrointestinal): Soft...

Extremities: The pelvis is stable...extremities are atraumatic.

Neuro: Unresponsive; unable to assess

Chest XR (x-ray) Portable: 12/27/13 at 1425:

Description: AP (Anterior/Posterior) chest shows the endotracheal tube four cm (centimeters) above the carina. The lungs are clear. No pneumothorax is identified. A bullet fragment projects at the level of the right hemidiaphragm.

Impression: No acute pulmonary abnormality identified. No pneumothorax.

AP (anterior/posterior) x-ray Abdomen:

Available Clinical Information: Post gunshot wound...

Description: AP view of the abdomen shows a bullet fragment in the right paramidline (situated adjacent to the midline) superiorly at the level of the right hemidiaphragm (Half of the diaphragm, the muscle that separates the chest cavity from the abdomen and serves as the main muscle of respiration). No abnormality of the bowel gas pattern is identified. Some small bullet fragments are noted at the left hemidiaphragm and in the left paramidline of the mid abdomen.

Impression: Gunshot wound.

CT (Computed Tomography) Thorax (an osseo-cartilaginous cage, containing and protecting the principal organs of respiration and circulation).

Endotracheal tube (tube that serves as an open passage through the upper airway to permit air to pass freely to and from the lungs in order to ventilate the lungs) and nasogastric tube (tube placed via the nasal passage that provides access to the stomach for diagnostic and therapeutic purposes) in place. Air is noted in the soft tissue along the right side of the chest. There is a large posterior probable mediastinal (undelineated group of structures in the thorax) hematoma (localized collection of blood outside the blood vessels). Air is noted within the heart and within the vessels of the liver. Large amount of free blood is noted within the abdomen. There is a huge hematoma surrounding the area of the left kidney. Extravasation (discharge or escape, as of blood, from a vessel into the tissues) of contrast is noted adjacent to the aorta and kidney with air noted within the soft tissue. On the coronal images there is suggestion that there may be extravasation from the aorta. As noted within the pelvis there is a large amount of free intraperitoneal fluid.

Opinion: Extensive trauma with air within the heart. Large posterior mediastinal hematoma. Air within the vasculature of the liver. Extravasation of contrast. The exact source is uncertain. On some images this appears at least a portion of this to be from the aorta. The left kidney shows a large area of hematoma and hemorrhage with air within the soft tissues adjacent to the left kidney. Large amount of free blood.

CT Cervical Spine without contrast:

History: Gunshot wound to back

Impression: No fracture detected.

Cranial CT without contrast:

... No acute intracranial hemorrhage acute infarct or intracranial mass detected.

Impression No significant abnormality detected.

ED Course:
On arrival found to be pulseless (no pulse) and apneic (not breathing), ACLS (Advanced Cardiac Life Support) protocol started - see nursing notes. (EI # 1, General Surgeon on call) ...paged as he is on Trauma call.

...(EI # 1) returned the page noting he is unavailable as he is operating and to "call someone else."

The hospital failed to have a back up plan to address situations when the on call surgeon/physician schedules and performs surgery when the physician is designated as the on call physician/surgeon.

Endotracheal Intubation:
Procedure Time: 1420

Patient was intubated for resp failure.
... patient was pre-Oxygenated prior to the procedure with 100% Oxygen...
... following medications were given to facilitate intubation: succinylcholine, etomidate.

The patient was intubated with a 7.5 ET (endotracheal) tube...
... ET tube secured at 23 cm (centimeters)...
Post-intubation exam reveal silent epigastrium, equal bilateral breath sounds, and positive color change of the end tidal CO2 (Carbon dioxide) monitor.

Post -intubation CXR (chest x-ray) good placement.

After ACLS and fluid resuscitation (PI # 6) was resuscitated for a brief period during which time I (ED Physician, EI # 5) spoke with (ED Medical Director) whom I asked to assist with obtaining a surgical consult who then contacted Dr... (CMO, Chief Medical Officer, EI # 3) as well as (Medical Director Trauma Services, EI # 4) to help facilitate general surgeon's evaluation of this level one trauma patient.

After initial fluid resuscitation and intubation - blood pressure came up...
hr (heart rate) initially was tacky (tachycardia - elevated heart rate) then came down to HR 50-70 and blood pressure (b/p) leveled off at roughly b/p 108/80, calls to multiple surgeons where (were) placed, fluid resuscitation was continued.

1430: ... (EI # 1, General Surgeon on call) paged for the second time. ...(EI # 1) calls back and states he is in another case (surgical case) and to find a different surgeon.

According to the surgery schedule dated 12/27/13 the on-call surgeon (EI # 1) was in surgery (Surgical Case A) at the time of PI # 6's arrival in the ED and was unable to present to the ED as requested by the ED Physician (EI # 5). Despite multiple requests by the ED Physician for the on-call surgeon (EI # 1) to come to the ED to further evaluate and treat PI # 6, the on call surgeon (EI # 1) did not present to the ED. The on call surgeon (EI # 1) started Surgical Case B on 12/27/13 at 1524 and ended the case at 1619.

The facility failed to ensure that on 12/27/13 the Medical Staff Rules and Regulations were followed as evidenced by failing to ensure Surgical Case B was not started because the on-call surgeon (EI # 1) had been notified that a patient (PI # 1) with an identified emergency medical condition was in the ED awaiting a surgical consultation. The on-call surgeon did not report to the ED at the times requested. The patient (PI # 6) died in the ED on 12/27/13 at 1625 while waiting for further surgical evaluation and treatment of an identified emergency medical condition. This failure posed an immediate threat to the health of PI # 6 because the patient required surgical services ( ED Physician not a surgeon).

1440: Pt rolled to CT scan. 4 nurses and respiratory therapist accompany stretcher. At this point I (ED Physician) was still unable to obtain a surgical consult - he (PI # 6) had been partially resuscitation (resuscitated) - I sent him to CT for a trauma scan. During the CT he (PI # 6) required ACLS intervention - see nursing notes.

1455: Pt. enters PEA (pulseless electrical activity) and chest compressions are administered en route to TB01 (trauma bay). ACLS, fluid resuscitation.

1456: Paged ... (EI # 1) who stated he is about to begin surgery on another patient.

1500: Advanced CPR (Cardiopulmonary resuscitation) performed.

1504: Palpable pulse and sinus tachycardia...

1510: Blood bank called for 2 units of PRBC (Packed Red Blood Cells) and 2 units of FFP (fresh frozen plasma).

After speaking with Radiology and repeated cardiac arrests the decision was made to do an open thoracotomy - (PI # 6) likely had a hemothorax, possible a tamponade (accumulation of fluid in the pericardial space - space surrounding the heart) and aortic injury along with his abdominal injuries, ... (EI # 7, Cardiovascular (CV) Surgeon on call) was called and emergently came to the ED.

1515: ... (EI # 7) at bedside.

1517: Open thoracotomy (surgical cut made to open the chest wall) with pericardial window performed. Small incision made to pericardial sac - no bleeding noted. Wound closed by ... CV Surgeon (EI # 7) and ...(EI # 5, ED Physician). No hemothorax (accumulation of blood in the pleural cavity), no aortic injury found.

1525: 32 F (french) chest tube inserted into left chest cavity and secured... by ...(EI # 7, CV Surgeon) and ...(EI # 5, ED Physician).

1600: Advanced CPR performed. ...(EI # 1, General Surgeon on call) paged and spoke to ...(EI # 5, ED Physician). (EI # 1) "request" transfer to ...(name of receiving hospital) as his (PI # 6) injuries are "to" severe to be adequately cared for here.

1605 ...(Name of receiving hospital) Trauma Service has accepted via TCC (Trauma Communication Center). Discussed with family.

1611: PEA (pulseless electrical activity) (PEA - cardiac arrest in which a heart rhythm is observed on the electrocardiogram that should be producing a pulse, but is not) - ACLS protocol.

1612: ...On-call surgeon (EI # 1) paged and responds he is coming down from OR (operating room).

1625: Time of death.....

Condition: Expired...

Date of Disposition: 12/27/13

Time of Disposition: 1625

Certified Medical Emergency: Yes

Clinical Impression:
1. Trauma alert
2. Trans Abdominal GSW
3. Catastrophic intraabdominal trauma/hemorrhage secondary to (blank - no documentation) .
4. Cardiopulmonary arrest

Trauma Resuscitation Record:
Documented by the RN Trauma Team Leader

Patient Name: PI # 6
admitted : 12/27/13
Arrival time: 14:13

Name of ED Physician (EI # 5) - Time called: 14:10.
Time arrived 14:11.
Present upon pt arrival: Yes...

Name of Surgeon on call for trauma (EI # 1, General Surgeon on call)
Time called 14:16.
Time arrived: (A single line is noted in the area on the form, but no time is documented.)
Present upon pt. arrival: (Blank - no documentation.)

Pre-hospital Interventions:
Airway: Nasal
IV size: 18 gauge
Site: Right AC (antecubital)

1415: Pt in ED via ambulance for evaluation of injuries s/p (status post) GSW, 2 GSW to back per medic. A & O (alert and oriented) en route, became unresponsive in ambulance entrance. ... TB01 (trauma bay), PEA (pulseless electrical activity) on monitor, chest compressions...(EI # 5, ED Physician) at bedside. Agonal respirations (abnormal pattern of breathing characterized by gasping, labored breathing, accompanied by strange vocalizations and [DIAGNOSES REDACTED] (movement disorder) approximately 4 / (per) min (minute).

1416: Advanced CPR performed. No palpable pulse.

1420: Palpable pulse. Doppler BP 70. Pt. intubated by (EI # 5) with 7.5 ET tube - 23 cm. CO2 (Carbon Dioxide) change (method to confirm tracheal intubation and detect esophageal intubation.) and breath sounds auscultated.

1430: ... (EI # 1, General Surgeon on call) paged for second time and given update on pt. (patient). Stated he was in another case and to page another surgeon.

1440: Pt. wheeled to cat scan on stretcher with 4 RN escort and respiratory therapist.

1455: While leaving cat scan pt. went into PEA rhythm on monitor. Chest compressions started en route to TB01.

1500: Advanced CPR performed. No palpable pulse.

1504: Palpable pulse. Sinus tachycardia on monitor.

1510: Blood bank called for 2 units PRB (packed red blood cells) and 2 units FFP (fresh frozen plasma.)

1515: ...(EI # 7, Cardiovascular (CV) Surgeon on call) at bedside.

1517: Open thoracotomy with pericardial window performed. Wound closed...Small incision made into pericardial sac - No bleeding noted.

1525: 32 F Chest tube inserted into L (left) chest cavity by ...(EI # 7, CV Surgeon). Secured...

1600: ... (EI # 1, General Surgeon on call) paged and spoke with ... (EI # 5, ED Physician). (EI # 1) stated to send pt. (patient) to another facility because we were not able to care for (PI # 6's) injuries.

1605: Trauma Coordinator spoke with TCC and Air Evac to transfer pt (PI # 6) to (name of receiving hospital)... (EI # 5, ED Physician) spoke with (name of physician at receiving hospital) and ... (physician at receiving hospital) accepted pt. Air Evac en route to transport pt.

1611: Pt into PEA rhythm on monitor. Chest compressions with ACLS meds performed/given.

1618: No palpable pulse... Chest compressions / meds continued.

1625: Pt pronounced dead by ... (EI # 5, ED Physician) Chest compressions discontinued. No palpable pulse. Idioventricular (abnormal heart rhythm produced when the ventricular signal is transmitted by cell-to-cell conduction between the heart muscles and not by the conduction system) rhythm without pulse noted on monitor...


Patient Name: (PI # 6)
Physician: (EI # 1/ General Surgeon on-call)

Date of Consultation: 12/27/13

Trauma Note:

History of Present Illness: The patient was brought by ambulance in extremis to the emergency room after being shot in the back. At the time of the patient's arrival, I was in the operating room and could not come to the Trauma Bay. I gave specific instructions at that time to call another surgeon in a different group that would have been on call at that time. Called again in the operating room and again I told them it was impossible for me to stop the procedure, that they would have to find another surgeon. I then called back down to the emergency room and for some reason they had sent the patient to the CT scan at that time. On further discussion, I noted the patient was being seen by (EI # 7, Cardiovascular (CV) Surgeon on call) for injury. In his mild extremis, the patient was being taken care of by (EI # 7) at that time. ...(EI #7, CV Surgeon ) then came to the operating room and discussed with me that he had performed an emergent thoracotomy after reviewing the CT scan. We discussed the findings of the CT scan at that time. The patient was felt to have most likely a "nonsurviveable" injury. We called back down to the emergency room and they had not found another trauma surgeon at that time. I discussed with the ER physician that he (PI # 6) might be best transported to a level 1 trauma center. However, he continued to be unstable and they were unable to do so. At the time of my arrival, the patient had basically been in a continuous code and had succumb to this mortal injury. CT scans were reviewed, and patient again had a mortal, nonsurviveable injury. We were going to bring the patient (PI #6) to the operating room prior to his death; however, he would have certainly succumbed to his injuries in the operating room as well.

Assessment: Mortal gunshot wound to the back involving multiple organ systems with massive air embolus to the heart, mediastinal hematoma, pneumobilia (presence of gas in the biliary system - organs and ducts (bile ducts, gallbladder, and associated structures) that are involved in the production and transportation of bile) with fractured liver. There appeared to be a fractured left kidney extravasation ( to pass by infiltration or effusion from a blood vessel into surrounding tissue), possibly from the aorta versus these organ systems, giving a nonsurviveable injury.

H. Interviews:

ED Manager, EI # 10:

During an interview on 1/14/14 at 9:02 AM the ED Manager/EI # 10 said she heard several trauma alerts on 12/27/13. According to the EI # 10, the surgeon on call said he could not come to the ED because he was in surgery. The Trauma Coordinator was attempting to find another surgeon to see the ED patient. When asked if ED staff was ever able to locate a surgeon the Manager said, "Not to my knowledge." EI # 10 was asked what is typically done when the on call surgeon cannot come to the ED as requested. According to EI # 10, it is the responsibility of the on-call surgeon to specify another surgeon to contact if the on-call physician is not available. EI # 10 stated, "There is not a formalized second back up."

ED Medical Director, EI # 2:

During an interview on 1/14/14 at 9:41 AM the ED Medical Director, EI # 2, stated he was aware the ED Physician (EI # 5) was having trouble getting the on-call surgeon to respond to his request to see a patient (PI # 6) in the ED on 12/27/13. The surgeon was in the Operating Room and did not know when he could come to the ED. Due to the loss of vital signs and a penetrating chest wound the patient's chest was opened by the cardiovascular on-call surgeon (EI # 7). Because no massive amount of bleeding was found, PI # 6's bleeding was determined to be intra-abdominal (within the abdomen). The trauma team was still trying to "reach" the on call surgeon (EI # 1) as well as other surgeons. At some point, (EI 3 1, General Surgeon on call) said to transfer the patient (PI # 6). EI # 2, stated there is no designated back up policy and procedure for on-call physicians.

Trauma Coordinator/EI # 9:

During a telephone interview on 1/14/14 at 10:25 AM the Trauma Coordinator/ EI # 9 stated he was working on the patient (PI # 6) in the ED on 12/27/13. The patient needed to be seen by the on-call surgeon. EI # 9 verified (EI # 1, General Surgeon on call) was the on-call surgeon. A trauma alert was called prior to PI # 6's arrival in the ED. The alert involves notification of the trauma team including notification of the on-call surgeon. EI # 9 said he knew the on-call surgeon, EI # 1, was notified about the admission of the trauma patient to the ED. EI # 9 was asked if the on-call surgeon presented to the ED and he said, "No." After PI # 6 coded and was intubated, the ED physician (EI # 5) asked the trauma team if the on-call surgeon (EI # 1) had responded to his request to see the patient in the ED. EI # 5, ED Physician asked staff to page the on-call surgeon (EI # 1) again because an x-ray indicated the patient had abdominal issues. "Got word down" from the OR that the on-call surgeon was in surgery and we (ED staff) needed to call another surgeon. The ED Unit secretary was on the telephone with the on-call surgeon's group who advised EI # 1 was the surgeon on-call. EI # 9, Trauma Coordinator was asked if staff tried to contact another physician from the on-call surgical group and he said yes, Dr. (last name of surgeon), but the physician was out of town. EI # 9 stated he called the Trauma Services Medical Director, who advised him to call another physician in the on-call surgeon's group. "(EI # 1, General Surgeon on call) did not come to the ER until after the patient (PI # 6) was dead. He did not step foot in the room (Trauma Bay 1). After the patient was pronounced, the surgeon on-call (EI # 1) spoke with Dr...ED Physician (EI # 5)."

According to the Trauma Coordinator (EI # 9), after the CT (Computed Tomography) scan, the radiologist said PI # 6 had air in his heart. The cardiovascular surgeon (EI # 7) did an open thoracotomy and no massive bleeding was found. The ED Physician (EI # 5) requested (EI # 1 General Surgeon on call) be paged. The on-call surgeon (EI # 1) returned the call from the OR and was placed on speaker phone in trauma room 1 in the ED. After (EI # 1) was notified about the thoracotomy he said, "Ship... (PI # 6) to Birmingham (name of large city with a Level 3 Trauma Center)." According to the Trauma Coordinator (EI # 9), he began initiating the transfer for PI # 6 after acceptance of the patient by the physician from the receiving hospital. The patient was not transferred because (patient) arrested and expired in the ED.

Trauma Team Leader/ EI 11:

During an interview on 1/14/14 at 11:11 AM the RN Trauma Team Leader (EI # 11) said a trauma alert was called on 12/27/13 after the ED was notified by EMS staff they were bringing an alert and oriented patient (PI # 6) with two gunshots wounds via ambulance to the ED. PI # 6 declined en route and was provided respiratory support via an ambu bag (used for an artificial-respiration device consisting of a bag that is squeezed by hand) by EMS personnel on arrival. PI # 6 had agonal respirations and was in PEA (Pulseless Electrical Activity) per the monitor. Chest compressions were initiated and PI # 6 was intubated. The patient was resuscitated and basic trauma protocol continued. At 14:30 the Team Leader said he was informed by the ED Charge Nurse (EI # 12) that the surgeon on call (EI # 1) had been paged for the second time to come to the ED to evaluate PI # 6. PI # 6 was taken for a CT scan, coded and was resuscitated. The preliminary CT results indicated possible cardiac fluid and or/blood in the patient's heart. A thoracotomy including a pericardial window was performed by the on call cardiovascular surgeon, EI # 7. No significant blood was found and there was no pneumothorax. A chest tube was inserted. As the ED Physician (EI # 5) was closing the patient's chest, he asked staff to page the on-call surgeon (EI # 1) again. The ED Physician (EI # 5) advised the on-call surgeon (EI # 1) about the patient's current status via speaker phone. The on-call surgeon (EI # 1) gave instructions to send the patient (PI # 6) to another hospital because, "We are not able to care for his injuries." Arrangements were initiated for a transfer including the acceptance of the patient by a physician at the receiving hospital. The conversation between the ED Physician and the physician at the receiving hospital was conducted on speaker phone in the trauma bay. According to the Trauma Team Leader (EI # 11) the accepting physician was, "Upset that we had the patient (PI # 6) so long and the patient had not been to surgery." The patient was not transferred because he coded and expired. The Team Leader was asked if the on call surgeon ever responded to the ED and he said, "Not to my knowledge. I never saw him."

ED Physician/ EI # 5:

During an interview on 1/14/14 at 12:03 PM the ED Physician (EI # 5) assigned to PI # 1 said he called ... (EI # 1, General Surgeon on call "trauma surgeon on call") on 12/27/13 to come to the ED to evaluate PI # 6, but, "He (EI # 1) wouldn't come." The other surgeons in the on-call surgeon's group were contacted when the on-call surgeon did not respond. One surgeon was out of town and the other surgeon was in surgery. "He (PI # 6) needed a surgeon to open his belly. I can't do surgery." Although the patient was accepted by another hospital for transfer, PI # 6 expired before the transfer was effected. According to EI # 5, hospital policy dictates if the on call surgeon cannot respond the circulating nurse should call another surgeon. EI # 5, ED Physician stated there is no policy and procedure for back up call regarding on-call physicians.

On Call Cardiovascular Surgeon/ EI # 7:

During an interview on 1/14/14 at 1:30 PM the Cardiovascular (CV)Surgeon on call (EI # 7), said he asked to evaluate PI # 6 by the ED Physician on 12/27/13. EI # 7 performed a thoracotomy and inserted a chest tube. There was no blood and the patient's heart was beating. It was, "Pretty evident the bullet had not gone above the diaphragm" because there was no blood. EI # 7 said he went to the OR to the room where the on-call surgeon (EI # 1) was performing surgery and advised him of PI # 6's status. According to EI # 7, the on call surgeon (EI # 1) replied, "I'm busy. They'll have to get somebody else."

RN Trauma Team Member/EI # 13:

During an interview on 1/14/14 at 1:46 PM, the RN/Trauma Team Member, EI # 13, verified (EI # 1) was the trauma surgeon on call on 12/27/13. EI # 13 said she was in the trauma room and heard the ED Physician (EI # 5) via speaker phone tell the on-call trauma surgeon (EI # 1) the patient (PI # 6) "needs surgery." According to EI # 13, the on-call surgeon (EI # 1) said, "Get... (patient) out of here. We can't do anything for (him/her)." EI # 13 said the on-call surgeon (EI # 1) did not see PI # 6 while the patient was in Trauma Bay One. EI # 13 said she also heard the ED Physician (EI # 5) speak with the physician at the receiving hospital who was "upset," but accepted PI # 6 as a transfer. The patient was not transferred because he expired in the ED.

RN Trauma Team Member/ EI # 14:

During an interview on 1/14/14 at 2:05 PM, the RN trauma team member (EI # 14) said she was assigned to the team caring for PI # 6 on 12/27/13. EI # 14 verified the on-call trauma surgeon on 12/27/13 was (EI # 1, General Surgeon on call)