Question for the doctors: Emergency procedures during disaster situations

I never know whether to put these types of questions in IMHO or GQ, so bear with me.

Discovery Times had on an hour long show about the Oklahoma City bombing today. (Can you believe next year will be ten years?) Anyway, one of the children was rescued and rushed to the hospital with a hunk of rock imbedded in his skull. His father is at the Red Cross building two blocks away from the hospital awaiting word on where his son is, not knowing his toddler is in surgery at the hospital.

This got me thinking about how hospitals handle disasters. You get a rush in of injured patients, in the case of the OKC bombing, some of them children. Obviously you don’t know where the parents are and cannot obtain permission to operate or even make a copy of the insurance card.

At that point, does the hospital say “Screw it” and start taking care of patients with the only priority being saving lives? On Sept 11, did NY and Washington DC hospitals even worry about keeping charts?

I don’t want this to come across as cold, that the billing department should be keeping track of every morphine drip and every cotton swab used in the middle of a disaster, and I know OKC and Sept 11 were major exceptions. But what happens when there’s a huge influx of patients from a sixteen car pileup on an icy road? Does the Good Samaritan rule kick in at that point, and petty administrative details like insurance cards and invoices fall by the wayside?

If someone is in iminent danger of death, even when there ISN’T a disaster going on, the priority is saving a life and they’ll sort out insurance later. I know this from experience, both mine and others.

In a truly massive disaster there’s a concept called “triage”. Actually, they use a variant of this technique in the ER during normal times to decide who to see first. In the context of a major disaster, however, they divide everyone into three basic groups (and no, these are not official names):

  1. “Walking wounded” - they’re hurt, but they can wait, maybe wait for many hours, without significant danger

  2. Those who need treatment right now or face a real danger of dying

  3. Those who can’t be saved.

So, in a real big disaster folks from the first group won’t see a doctor for quite a bit. They might even wind up helping each other, or holding IV bags, or something like that if all they have are some bad cuts or minor burns. The folks in the second group will get the immediate attention. Folks in the third group will get comfort if available (because sometimes the painkillers and stuff run low) but will not receive treatment beyond that.

Harsh, yes, but it wouldn’t be right to spare resources for someone with no chance of survival when those same resources could save other lives and limbs.

More detail than that will have to wait for someone like a doctor with actual experience/training in this area. Or a nurse - nurses often wind up doing the sorting in these situations. Not a job I’d want!

I understood triage. I just wasn’t sure when permission to operate was required. Say a family has a religious objection to invasive medicine and the doctors operate. Can they be open to a lawsuit, or does the Good Samaritan rule apply to doctors as well?

IANA MD, or even a medical person, but I work at a hospital and participate in the annual disasrer drills. Each time they simulate something different; plane crash at the airport, terrorist bioweapon attack, etc. Nobody is looking for insurance coverage while this is happening. Our local disaster planning is county-wide, and victims are sent to the hospital best equipped, or least overwhelmed, to handle the medical issue. The drills I’ve been part of have never continued far enough to deal with billing questions. Presumably in a large scale disaster there will be enough insurance carriers with liability coverage to handle the uninsured people caught up in the thing.

This very same issue is addressed on a smaller scale almost every day. EMTs pull unconscious victims out of car wrecks every day, and start a chain of medical treatment without regard for whether the victim can pay for it. That victim will get transported to a hospital and will receive very high cost care, even a wallet can’t be found and their name isn’t even known.

I think your question is trying to determine the point at which “good works” begins to conflict with “good business”. My hospital remains a not-for-profit institution, not all that common anymore. I personally know of a case whenwe caught an accident victim stealing medical supplies from our ER storeroom. The hospital might have just called the cops, but instead assigned a social worker to investigate. The thief was a poor mom who needed supplies for her children, and we ended up giving the stuff to her. I heard the CEO say that we “donated” about 30 million a year in medical supplies and services to our community. That’s how we consider treatment of the uninsured – a charity that we raise money to be able to do.

I think that’s part of it. I was just wondering if the mindset of a hospital shifts during the disaster, and it’s “Hang the insurance, get this kid to the OR, stat,”, or if there was some bean counter somewhere still frowning at the “waste of resources.”

Do hospital workers even care about money at that point? I know during Sept 11 McDonald’s was donating food to Red Cross workers, and Domino’s was delivering pizzas to fire stations. Do hospitals “donate” their time and resources without regard to payment during disasters? Or do they attempt to sort out insurance issues after things calm down?

One of the areas of Houston hardest-hit after Tropical Storm Allison was the Medical Center area, which is where most of the major hospitals are located. Several general hospitals were unable to treat people because of flooding and loss of utility services. The Veteran’s Affairs hospital delivered babies, something it normally doesn’t do (even for veterans); and MD Anderson treated non-cancer patients, again, something it generally doesn’t do. Both hospitals took in patients because they were among the few hospitals in the area capable of doing so, even though these patients did not meet the normal criteria of veteran or cancer patient.

I worked at MD Anderson in the billing department after Allison, and it took a while to get insurance information and everything sorted out, but the emergency treatment its doctors gave was eventually billed out and reimbursed. Obviously, insurance information is not a priority, but medical records were kept.

I do know that most cities do have a plan in place for major disasters that takes hospitals into account. The individual hospitals, in turn, have disaster plans in place that provide for the kinds of care and staffing that would be needed in the event a specific disaster (say, a plane crash or major traffic accident or weather-related disaster) were to happen.

Robin

In a true disaster situation hospital workers are not thinking about money and for a couple of good reaons.

First of all, most clinicians’ basic instinct is to save life and limb and in a true emergency situation, especially one on the scale of disaster, this instinct would be the overriding force directing them. Administrative *guidelines * would still be followed as the situation permitted, but the real push would be to preserve life.

Also, it is my understanding that most major hospitals provide a certain amount of charity or pro bono work. In some cases this is even a requirement to receive state funds and federal matching funds. These charitable $$$ are not just reserved for emergency situations, but this would certainly be one use of them.

I know I have been lucky, but most bean counters I have had to deal with have been reasonable people who can even bend a little when presented with the facts. I have also found that groveling sometimes helps when I need something for a client really quickly. But given the nature of their responsibility to their organization, I think that even in an emergency or disaster situation they would press for some accouting retrospectively.

A nurse friend of mine is the bioterrorism liason for his hospital system. In a disaster of great magnitude they will not only be expected to preform the routine triage, described very well earlier by **Broomstick ** but will proceed on to some sort of uber-triage of the entire hospital to discharge anyone who can reasonably survive outside. All of the emphasis shifts to just trying to save as many lives as possible, even shifting patients between hospitals and strategizing as a *region * as opposed to individual hospitals and organizations. I don’t think the bean counters figured into the scenario at all at this point in the game. :frowning:

I know this is a slight divergence from the point of the OP, and it’s just a minor correction, but in the spirit of fighting ignorance (hope you don’t mind)…

In a triage situation there are actually 4 categories of patients. You correctly identified 2 of the 4, but there’s a category in between your first 2, and people who are doing triage aren’t expected to determine whether or not an injured patient can or cannot be saved, so your #3 is actually a part of your #2. Triage patients are categorized as follows: [ol][li]MINOR – Those are the patients who are what you referred to as “walking wounded.” Their treatement can be delayed for up to 3 hours. [/li][li]DELAYED – Those are injury patients, unable to walk, but who are breathing normally, have good perfusion (blood is getting to the extremities – pressing the fingernail and seeing how fast it goes from white to pink, or taking the pulse at the wrist are good ways to tell), and their mental acuity is ok (they can perform simple commands). Patients in this category can wait up to 1 hour for treatment.[/li][li]IMMEDIATE – Those are patients who have failed any one of the above “tests” (accelerated respiration, radial pulse or capillary refill absent, or diminished mental acuity). Those patients move to the head of the line for, as the category implies, immediate treatment.[/li]DEAD – This one speaks for itself.[/ol] Here’s a good link that details the steps in managing triage.

Nope - I’m not an expert on this, I thought I had mentioned that.

Um… maybe not, but sometimes you just know.

I mean, if you’re in a situation where only the most basic of first aid is available - let’s say the bandages and medicine are running out, there’s been an earthquake so everything’s a mess, you haven’t got reliable clean water, Og knows when you’ll be resupplied, etc. etc. - and someone carries a person into your aid station who has third degree burns over 90% of their body… well, they might be alive, they might even be concious but you just can NOT save them with what you have available. Ditto for certain types of crush injuries. So, let’s say you’ve got 1 and only 1 liter of saline… do you give it to the 90% burned person who WILL die, or to the person who just had a foot amputated but stands and actual chance of suvival now that the bleeding has been brought under control and stopped?

There really is only one logical and moral choice there.

Fortunately, that’s not a common dilemna in daily life.

And if things are that dire … no, no one is going to be asking anyone for proof of insurance prior to treatment. Treat first, sort out the paperwork later.

While that certainly makes sense, and part of the triage process includes stopping bleeding and opening airways, any other treatment and first aid are not a part of triage. Triage is the step wherein the “first responders” are assessing what level of treatment each person requires – first aid, administering fluids, etc., aren’t done at that time. From my previous link (bolding mine):

As a Community Emergency Response Team volunteer, I’ve participated in many triage drills and training exercises, both as a “first responder” and as a victim, both for other trainees, as well as for firefighters practicing their own skills, and they really drive home the point that you cannot stop to treat patients during triage. You never know if there’ll be someone further down the line who needs even more immediate treatment, so everyone has to be assessed as soon as possible, for treatment later. That’s all triage is – assessment.

It was my understanding that there’s something called “implied consent” for situations like that—you assume the patient would want to live and receive treatment, and act accordingly.

Well, sure, but in real disaster situations the assessment may be not to use resources on someone who may be alive and even talking now, but can’t possibly survive.

I’ve known a number of “first responders” who did it as a living and not just a volunteer, and they all have hair-raising stories about encoutering mortally injured people who are lucent and talking. It’s not like they dump them into a gutter or something, but it’s something that has to be dealt with.

I didn’t express it very well - of course the triage person won’t be treating other than airways and massive bleeding, but even so – if it WAS a huge disaster how WOULD you assess someone with 100% burn coverage? Initially they may be upright and walking and talking but they won’t stay that way for long.

In Colorado the ER people are not allowed to mention payment or insurance at all.

When Wifecat and I were living in Denver she got a real bad urinary tract infection that she tried to ignore for two days, then was in agony at about 10 PM. She didn’t have insurance and we were broke (one reason why she tried to ignore the pain), but the ER was the only thing we could do. We went to the hospital and they took us in and we were honest and up-front “She is a foreigner without insurance and we don’t know what to do.” The nurse simply said “By law I cannot ask you for payment or insurance information and I am not the one to talk to about it, nor is now the time. When we are done someone will come talk to you.”

AFTER all was said and done someone walked in with a clipboard and took our information, Wifecat signed, we left and the following week we were contacted.

Which all comes down to saying that if they didn’t ask us for the info on a weekday with an empty ER, then I assume that during an emergency they are going to do the same. Probably admin people get called up with the rest of the off-duty people and they walk around with clipboards in the recovery rooms.

-Tcat

I was pretty sure that most (if not all) hospitals could not reject people from the emergency room for failure to pay if they were having a legitimate emergency. I dug up a cite that says that hospitals which accept Medicare are in fact bound by a law which states that. This was created to deal with a problem of some hospitals “dumping” poor patients off on other hospitals to prevent the hassle of trying to collect on bills that probably won’t get paid.