Hey, everyone - I can't even remember the last time I posted here, but I know it was multiple years ago. I've since resurrected a project of mine and have worked it almost to completion, but I have a question relating to technicalities in the plot and need some help. One of the scenes in my project involves a blood relative of my MC getting involved in a car accident. The relative is taken to the hospital, but the internal injuries are too severe to fix with surgery. She does not want life support, so she's put on a morphine drip to make her comfortable. My MC is this character's emergency contact, and I need the hospital to call her and inform her of the event. The problem is, I have no idea how this conversation would go in reality. I don't know what the hospital is allowed to say over the phone (or if there's a restriction at all), what has to be said when my MC arrives at the hospital, etc. Keep in mind that the characters ARE related by blood. This is one of the most important scenes in the work, so I really want to get it right. The part where my MC is sitting by the condemned character's bed, the eventual death, and the aftermath I can deal with as far as personal experience is concerned, so I'm not worried about any of that. The issue is with the phone call from the hospital. Any help would be greatly appreciated, as this is one of the only scenes that stands between me and a finished draft. Thanks!
http://www.ama-assn.org/ama/pub/physician-resources/legal-topics/patient-physician-relationship-topics/patient-confidentiality.page Hope that helps! So, by virtue of being a blood relative, if the injured person is over 18 there would still need to be express consent. Unless the MC has power of attorney over the patient/has actively been working with the hospital and the patient, they likely wouldn't disclose anything over the phone and would instead want the MC to have proof of identity. For explain, my father in law and mother in law got phone calls from the hospital regularly when FIL's mother was in the hospital, but FIL was her power of attorney and they knew who he was since he had been there pretty much every day since she went into the hospital. I was added to the contact list, in case anything happened, but I was added while I was at the hospital, and being that I was added by my mother in law, it was approved. But if there is more of a distant connection between the MC and the patient, then they may/likely will require her to show up in person with proof of identity. BUT you say she is the emergency contact? Then that may not be the case. Since I don't work in a hospital I can only speak from experience. The article might assist you further. If you know anyone or could research this directly at a hospital, or perhaps look on a hospital's website you may find more information regarding patient confidentiality and family care.
Having worked in hospitals for quite a few years, I can tell you that it tends to be all a bit random, really. Usually it's the nurse who either picks up the phone when the relatives call, or who phones next of kin. Once I heard an A&E nurse inform relatives of the wrong patient that their niece tried to commit suicide via overdose and which pills, all over the phone But also, much more often, I heard them discreetly ask the next of kin to come to the hospital. If the patient is alive but critical or in theatre etc, they'll say they are alive but it's urgent for them to come, but they won't divulge details first time they speak to them. If the patient is ok, then they'll phone in the first place. Once the next of kin is in hospital, they'll usually get to speak to the doctor about details of what happened, prognosis etc. In an emergency, next of kin makes decisions on patient's behalf, they don't need a power of attorney for that. The article on confidentiality is not really about this, because next of kin is not considered a "third party". Still, if the patient explicitly asked that certain information is not divulged it is unethical to break that, but if there is no such directive, it's ok to share the necessary information, in person if at all possible.
Thank you very much for your quick responses. My MC would be the next of kin, as the patient has no children, both parents have passed away, and the MC is the closest blood relative (sister). In this case, I guess the 'emergency contact' detail doesn't matter, right? My MC would be contacted as next of kin anyway, it seems. Anyway, assuming I'm following this correctly, the flow of events would be that the nurse calls my MC, tells her that her sister is in the hospital and that it is urgent for her to come in, and when she gets there the doctor could explain the situation (car accident, inoperable internal injuries, DNR, morphine drip, etc). That's pretty much what I figured, but there was no way I was going to write such a critical scene without knowing the details. Thanks for the help!
In the US, they cannot say much at all without proof they are talking to someone authorized to receive such information. Look up the HIPAA laws. They are very strict, and any health care person or organization who releases information to anyone not authorized to have that information, or even exposes such information such that it COULD end up in the wrong hands, is subject to some pretty severe penalties.
I thought HIPAA might prove to be a pain to work around, so that doesn't surprise me. I'm not looking to get bogged down in a bunch of legal stuff, so I can make my scenario adaptable. I haven't written anything yet, so I can still fine-tune the details so as to keep things as simple as possible. How would this change things? The patient is awake after the event and is on a morphine drip, since she does not want life support and her injuries are inoperable. She consciously asks the nurse to call her sister (the MC) and ask her to come to the hospital, since she knows it will be the last time she gets to talk to her. How does this affect what can and cannot be said over the phone and when the MC arrives? The details don't much matter for me. What matters is that the MC gets a call that brings her to the hospital so that she can have one last conversation with her sister before she passes. I can adapt the situation to whatever will make this chain of events possible. I did a bit of searching for next of kin, HIPAA, and emergency contact laws/regulations/etc, but results are surprisingly sparse in regards to the matter that's relevant to my scenario. Again, thanks for all the help and insights. It's all greatly appreciated!
Absolutely. Once your MC is in the hospital, they'd be able to confirm her identity and talk to her as needed Whatever the patient authorised, as long as it was recorded clearly in the notes ("yes you have my permission to discuss everything with her") there are no restrictions on what can be discussed with the next of kin. Patient's notes are legal documents and don't need any further authorisation to be deemed sufficient. Obviously, if the patient is still conscious, then she'd get to talk to her as well, but sick people often have no energy or desire to go through details of their medical situation with their loved ones. Doctors and nurses will discuss that, away from them if they find it too distressing (which often they do), and the patient will most likely just want to talk to her relatives, tell them she loves them and all things like that. Just keep in mind that all these things are emergency situations, there are protocols to deal with all the legalities in that setting because legalities must not come before patient's best interest. Good luck with the story!
There is a vast difference between an emergency contact such as ICE in your cell phone and the consent to release information. All emergency responders routinely look through cell phone contacts of an unconscious person to contact family members. Even citizens are aware of ICE (in case of emergency) listings as when I wrecked my motorcycle. The woman who found me called and my daughter answered, she said, "I don't know who you are and I dont know who he is, but I just found this man lying unconscious in the middle of the highway, he wrecked his motorcycle. At a hospital with the HIPPA laws, no nurse would release sensitive information about the condition of a patient without clear consent from that patient without risking their career. However... people are people and in a critical situation, may divulge information to an obvious loved one, especially if they could hear the concern in that person's voice, just as a compassionate human being... "You really need to hurry and get down here."
That helps to clarify things a lot. So, in the case of my scene, it would make more sense for the first responder (a cop or a medic) to call my MC from the victim's phone and tell her that she's injured and being taken to ABC hospital. Then when she gets there and provides identification the doctor can tell her the details. Does that sound realistic? I can always take the easy way out in the hospital by saying something along the lines of: "After entering the hospital she proceeded to follow the protocols and eventually found herself in the waiting room." Then the doctor can come out and say the stuff that needs to be said. I'm assuming the first responder (in this case it would be better for it to be a cop or medic) would realistically only provide my MC with the fact that there's been an accident and the location of where she's being taken, right? Thanks for all the help - this is very informative. Who'd have thought writing a simple car accident scene would be so tricky?
In an emergency, first responders and ambulance are almost never, in my experience, involved in contacting anyone because it is irrelevant at the time. What is of parammount importance is to stabilise the patient and bring them to hospital asap. Cops may investigate the scene, locate identifying information like a wallet, check the licence plates etc. as the help is being administered by medics, but there is no time to deal with calls to family there and then. Also, it is not up to a cop to give this info. Relatives knowing isn't the urgent matter, stabilising the patient and bringing them to the emergency department is. After the patient arrives to the emergency department, floor doctors and nurses take care of the patient whilst another nurse (usually triage nurse) speaks to ambos/cops/first responders about what happened, and gathers as much info as she can about the accident and who the patient is, next of kin if available etc. So I wouldn't have first responder or a cop contact the family, the nurse from the hospital almost always does that. But, because all kinds of things can theoretically happen, you can really write it whichever way you prefer. There's bound to be one cop or an ambo who called the relatives from the scene, no matter how inappropriate that might have been.
I became a medic in 1993 and I can tell you the first thing a patient wants is their family members notified. I've been faced with a 45 minute transfer to the hospital more often than not as I ran rural EMS. After establishing IV's, and stopping bleeding or stabilizing the patient as needed, there is more than enough time to do this for the patient, and it does wonders to calm them down, get their heart rate slowed. As I said about nurses, medics are just people too with emotions and faced with a live, breathing patient giving you consent, and even asking you to call the family member, I have done this many times. People all want the same thing when they are dying or think that they are. the super rich and the poorest of the poor all just want one more minute with the ones that they love, death is the great equalizer. Now, you also have some cowboys that ride in the back of these trucks who don't follow protocols. If the patient is unconscious and in a bad way, or even not, they feel compelled to call the family and yes, we do look through the phone for an emergency contact, it happens every day. I considered it a very important part of my job. Of course if you are working a heart attack, doing CPR alone, pushing drugs and defibrillating, there is no time for this. But this is the exception, not the rule. So, if your victim is not conscious, it would completely believable to say the medic looked through the phone during transport and divulged information. Some divulge more than they are supposed to not knowing the actual relationship of the ICE contact, but you can't cure stupid.
I am an EMT and in our state it is never acceptable to leaf through patient belongings. We package the patient, who becomes John/Jane Doe if unidentified and unconscious. We deliver to the hospital and they start the process of finding out who this person is. If there is an obvious purse or wallet we will transport it with us, but we are not permitted to root through said purse.
What if the patient is conscious and asks the EMT to call her sister? Would they do it on the spot (assuming there's time to do it, as Felipe said), or would they wait until they got to the hospital? Realistically, I don't care as much about what is legal vs illegal or moral vs immoral - I care more about what an EMT in such a situation is likely to do regardless of legality. I know ethics will vary from person to person, but as long as the actions taken are reasonable to expect in such a situation, it works for me. For the record, the story is set in the state of Pennsylvania, if that makes any kind of difference. Thanks to everyone who's been posting in this topic. All your posts have been very helpful!
There is a difference between "leafing through a patient's belongings" and accessing their cell phone. Implied consent takes over here, just as you have to assume that an unconscious patient would consent to care, you also have to assume that an unconscious patient would want their family notified if they were in critical condition. I find it hard to imagine that I can cut every stitch of a person's clothes off to look for injuries, but it would be considered an invasion of privacy if I looked for an emergency contact for a person in critical condition. Implied consent is a legal term that all medics learn in order to pass their state certification. In the case of a person asking you to call a family member say if they are totally spinal immobilized (strapped down to a backboard) there is no question of consent. Not only have I ran EMS in Texas for years, but I have also taught it at two local universities. EMS goes far beyond bandages and needles. Say if you deliver a child 40 minutes away from the nearest hospital and that child is obviously dead, beyond resuscitation. The mother will be in a state of mental shock seeing this, she isn't thinking clearly. The child will be taken to the morgue, then the funeral home upon arrival at the hospital. The burial usually takes place within three days, then three weeks later she hears a sermon at her church about how a person must be baptized. She will then be distraught (even though I don't believe for a second that God would hold this against an infant, it may be very important to the mother but she does not think of it at the time.) I taught my students that should this occur, to ask the mother if she wants you to baptize the child. If she agrees, you simply open a bottle of sterile water and pour some on the forehead saying" I baptize you in the name of the Father, the Son and the Holy Spirit." I have held patients hands, talked to them, called the family, my x wife even sang hymns in the back along with seniors. A lot of drama plays out in the back of those trucks and in my opinion and legally, calling a family member would never be considered unethical in a critical situation, rather it would be appreciated.
A conscious patient consents as Felipe said. However, I am not rooting through pockets to find a cell phone or a disheveled vehicle. How do you gain access to that cell phone without rooting through personal effects. There would be stiff reprimands for an EMT in my state if they arrived at the hospital with an unconscious patient and the family informed them that they were contacted by EMS. It is not within our scope, and simply not permitted. It is not covered under implied consent. I have found that speaking with other people over various EMS forums though that things are different between states and even certifying agencies. What is protocol in my county is not protocol in the county north of me. I'd have to disagree that holding patient hands, talking and singing to them falls in the same category as contacting next of kin though, even if it is permitted in the grand state of Texas. Us yanks must be more rules oriented than you southern midwesterners. LOL
I personally wouldn't and haven't ever hesitated to call the family especially if the patient is critical and may not live very long.
Hey Felipe, all that you said is very familiar to me, and the point about baptism you mentioned, absolutely, there are so many intricacies of the job, but the most important thing is the welfare of the patient and in an emergency, common sense must prevail. Well done, I can tell you are a good teacher and a good professional
The welfare of the patient always comes first. In rural EMS, more often than not you have a 40 minute plus run time. Plenty of time to establish 2 large bore IV's if needed, attach monitor, oxygen, bandage/stop bleeding, Trendelenberg then monitor. Usually, in trauma the clothes are cut off anyway so a phone is not hard to find. Once the patient is stable, it is an everyday occurrence to place a call for them when asked, or place a call to a family who might just have a few minutes with a loved one. What blows me away are some of the requests from the cops on the scene. We had a kid trapped, T boned in a Camaro, rain pouring in the broken out window on him while we used the jaws. An officer actually wanted us to hook onto the car and drag it clear of the road with him still in it. Once we got him out and in a warm ambulance, the cop threw both back doors open and asked for an insurance card. I closed the doors, a minute alter, he swings them open again wanting a drivers license. Another time a kid had a through and through gun shot wound to the head. i was about to direct a helicopter to land on the farm road when a cop screamed at me, "You can't stop traffic! We need to clear this road! We might have an emergency!"
Those cops sound like typical bureaucrats, with no appreciation for the reality of the situation It always makes me furious when pencil-pushing mentality interferes with patient care, but it seems to be everywhere. I once had a person on a hospital switch cancel my call for a blue light ambulance for a psych patient who looked like they had a big PE, just because she (the switch person) decided that the psych building is not an admin part of the hospital and therefore somehow not covered by the a&e department down the road. The patient died. Awful! Your perspective is really interesting because I only got to see that side of things as a med student, a few times, after that, I see them only from the point when they enter the hospital. Although in Australia we had doctor-lead ambulances (trauma consultant would ride with the ambulance personnel) that would go to those really serious accidents and perform surgery in situ if needed. But that was only experimental, I don't know if it took. Certainly here in the UK we have nothing of the sort. That's all very interesting, but we must not talk shop too much, or we'll bore everyone else senseless
Felipe we have the same issue with cops here. Thankfully with the volley unit I run with our chief IS a cop for the city we normally transfer to (also 45 minutes away). And since all we have are a few state troopers that service the area, they know not to mess with our chief. If one of the other chiefs are on scene, however it can be problematic. Our towns are so small that everyone knows everyone and it's never happened that SOMEONE isn't on scene that knows the patient if not is their next of kin. Shoot, half of our squad is related to at least one person in town LOL. But even on full blown codes we've not made that phone call. It's simply not permitted. We are lucky enough to have a highschool foot ball field close enough to use as a landing zone. Actually most of the tiny mountain towns here have a baseball field of some sort. We've never needed to land on a road. I'd probably threaten to cause enough damage to need to board and collar that cop for interfering with patient care as you tried to set up a landing zone. Cops are quite stuck on themselves and their power at times.
Jazz, I seem to recall speaking with a German out of hospital doctor that did the exact same thing as what you describe in Australia. I do know their ambulances are a thing to be desired and the United States could learn a thing or two about the safety mechanisms they have set up for the protection of the crew there.
We had a trauma doctor who responded via the aircraft once when a man was hung up in a piece of machinery. The call was prompted by the report that amputation was necessary due to massive blood loss and paramedics simply aren't allowed to do this. Dis-assembly of the machine was ruled out so9 the doctor made the call and did the amputation on the scene. This brings me to a point that I brought up in class. If you were using the jaws of life and a patient had one leg trapped under the dash and the vehicle caught on fire, would you or wouldn't you cut off the leg or just back out and let them burn? They would probably hang you from the highest tree but there is no question in my mind what I'd do, I'd save the life and lose the leg. I'd probably be fried in court but wouldn't have the nightmares of hearing them scream, I've had enough nightmares about EMS. BFGuru, my daughter ran with us and video taped wreck and fire scenes for the news. The incident where the young man was shot through the head got real heated between the cop and I about the landing zone. She said I pushed him, I swore I didn't. She insisted that I did and rewound the tape. The video caught it all very clear... Him, "We are landing in that parking lot!" pointing at a small, loose gravel lot surrounded by power lines. Me, "We will thump that aircraft if we put it there!" This is where I pushed him away as I waved at the aircraft hovering overhead, "Take no landing instructions other than mine, be aware of the power lines to the north and west, we are landing right here."
Felipe that would stress me out. I like having my designated landing zones. Even if we do have to drive up to fifteen minutes to reach them. Rural PA is still a lot more compact than rural TX and I think we have more tiny town close together than you guys do. I do recall the boy climbing a tree with his jumprope. He fell, hanging himself due to getting twisted in the ropes. Apparently no medics or BLS units were available, and they sent a medic from the next county over. Those guys got lost as my volley unit responded to the scene 30 minutes away. Where all the local units were, I don't know. I was at my interfacility transport job listening to dispatch over the radio, thinking "this is absolutely ridiculous" as no one could seem to direct any of the teams to the proper address. This is the problem with living up in the mountains, in the middle of no where. I'm actually looking at going into more clinical aspects. I tend to panic being responsible for other human life while driving a vehicle in inclement weather. I feel more of a sense of responsibility behind the wheel than I do in the back with the patient and my heart is in my throat most times while driving.
Tell me about stress. I had just started EMS classes and knew only enough to make me dangerous when this happened. We lived in a very small town, 1,300 people and I had only been in class about three weeks when my 13 year old daughter put a gun in her mouth and pulled the trigger. I was the first medic to arrive on her scene. We only had one ambulance and it was gone on a BS run for stomach pains. I had been complaining that when this ambulance was gone that we had no coverage. I was told that the rescue truck had everything we needed to "hold in place" until additional help arrived. That was not the case. The bullet didn't exit, it penetrated her basiler skull, through the sinuses and into her brain but the bleeding was severe. I needed suction to clear her airway. She was choking on pieces of brain matter, blood and tissue. The rescue truck arrived and another medic showed up. Being a really small town, she knew us and went to shit even though she had a lot more training and experience than I did, she was useless. I asked for suction and the portable suction didn't work. I called for a V vac ( a handheld, manual suction device that can suck up a whole can of chicken soup in one stroke). She found it, but she didn't have the catheter that fits on the end ( a rubber tube that fits on the end to insert between her clenched teeth) The end of the V vac was too large to fit between her clenched teeth. I was frantic... "Give me some rubber tubing!" I screamed. She used the flashlight and dug in the bag.... "I don't have any!" My daughter was choking and dying. "Give me a fucking nasal cannula!" ( the small tube that goes under your nose to give you oxygen in a hospital. She found that so I took my knife out and cut the large tube off of the end. I put one end in my mouth and inserted the other end into her mouth. I sucked out the blood, tissue and other crap to clear her airway. I gagged, but I kept doing it until the helicopter landed. The paramedic that landed knew me and saw what I was doing. the first thing that went through his mind was AIDS, I was sucking her blood into my mouth and spitting it out to keep her breathing. He said. "Felipe, stop that!" I told him, "this is my daughter!!" He too lost it and became useless. He tried to nasally intubate (shove a tube up her nose and into her lungs to breathe for her) which you never do with a basilar skull fracture ( I learned this later, by doing so, shoving the tube up her nose, he lacerated both carotid arteries by shoving bone fragments down her throat. This is what killed her, not the bullet.) So, my first call was sucking the blood and other tissues out of my own daughter's airway with a piece of rubber tubing and my mouth to try to keep her from choking. She died. I know stress.
In the UK, 'confirming identity' is often a matter of calling in a work colleague, flatmate, whatever, to physically identify someone since there are no IDs carried, as in Europe, and not everyone has a passport or driver's licence bearing their photo or can rattle off their insurance number from memory. Rules are more elastic in the UK because of this problem. Anyway, since emergency treatment is free (even for many foreign nationals, e.g. Turkish since we have a reciprocal agreement with the health services--our state service is also free) there is no necessity to identify someone the very second they arrive at the hospital. When my sister and her husband were involved in a serious car accident, her husband was the only one able to speak, and he told the ambulence crew my brother's name and phone number, since my parents live in France. He also told them the tax documents in the car with their names on related to the driver and passenger in the car, so the address etc was clear. The emergency services contacted my brother within half an hour, he contacted my parents, and everyone was at the hospital with her by the end of the day. The hospital gave my brother all the details over the phone without meeting him first. I think the situation is very different between the US and UK/Europe. There is less concern about litigation or who is going to pay (since it's free, or rather, paid for as we earn, anyway). Like Jazz says, it's usually the hospital that contacts, not the police, but in my sister's case, she was unconscious and they were being air-lifted to different hospitals, and her husband was determined to give them as much information as possible before he passed out! Luckily, the ambulence crew were great. Oh, yes--and all this happened on the morning of Christmas Eve. It was amazing that my parents managed to get a seat on the Eurostar.
