Opinion | To Transfer or Not to Transfer the Patient?

When I started down my professional path as an emergency physician, I had visions of flashing ambulance light bars, of helicopters landing to scoop up the dying, of intubations and chest tubes and fascinating overdoses. While I have experienced all of that and much more, I really didn’t realize how much of my life would be spent arranging transfers. It appears this is almost as important a skill as managing arrhythmias or performing sedations. Or say, typing.

Some days it feels like a job in sales. “Have I got a patient for you! High mileage 86-year-old with sepsis; he presents with acute kidney failure and a potassium of 6.5. But there’s more! We don’t have inpatient dialysis…what can I do to make this deal happen?”

During my time in residency at a large teaching center, we received transfers. As a resident, it was not uncommon for me to fly out, pick up patients, and bring them to our giant hospital with all of its specialties and resources.

But once I was out in the community I learned about how often it was necessary to transfer patients to other centers. It was perhaps less common in the days when we weren’t giving thrombolytics for stroke and when interventional cardiology wasn’t the gold standard for every heart attack. Still, there were plenty of other reasons: often for sick children or highly complicated medical or surgical conditions or simply because the patient requested it.

In the early days of my practice, this was done without the immense blessing of the recorded transfer line. As such, unrecorded conversations were often attended by salty language and unpleasant accusations and counter accusations about professionalism, parentage, and character. Happily, those days are gone; well, mostly.

However, the frequency of transfers has skyrocketed and this is especially true in the rural facilities where I have worked for so long. Because patients live longer, have more complex illnesses, and can survive more incredible physical insults, there is often good reason to send a patient to a hospital that has “all the things.”

Part and parcel to that reality is a fear of litigation for not doing everything possible. So, physicians in smaller, resource challenged hospitals are often fearful of keeping patients who might “take a turn.” I’m often told by hospitalists or surgeons that they “aren’t comfortable” keeping this or that patient.

I understand that. I’m often faced with things that make me uncomfortable; of course, thanks to the Emergency Medical Treatment and Labor Act (EMTALA) I just have to live with that discomfort. But admittedly, my interaction doesn’t last for days to weeks. Well, in the past it didn’t. Times have certainly changed.

The true peak of transfer misery came during the COVID-19 pandemic. When this complicated plague began ravaging the country, many of us in smaller hospital emergency departments found ourselves just stuck. We were told by admitting doctors, consultants, and administrators that the patients were too sick to stay and that they had to go. The problem was, just where should they go? No, where could they go?

The hard answer was often “nowhere.” We would call hospitals in concentric circles from our own: 30 miles, 50 miles, 100 miles, 300 miles away. The answer was usually, “We’re on closure, sorry, try again tomorrow.” Or “You mean there’s no hospital closer?” This went on for days to weeks for too many patients. Sometimes patients improved; all too often they just died — of respiratory failure, of MI, of sepsis.

We had hoped it would improve. But even now, with COVID-19 not nearly as bad as before, available beds and specialists are rare. Patients in need of something as common as removal of a kidney stone in the face of pyelonephritis may be transferred hours away, if at all. Patients who need care for acute cardiac events don’t always go in a timely manner. And psychiatric patients? Adult or pediatric? Transferring them is nearly impossible, especially if they are violent or have no insurance.

On the other hand, sometimes transfers are requested not because it is absolutely essential but just because it might seem the safest possible course. Again, understandable. But there are some things about transfers that bear consideration.

Transfers are often problematic because there just aren’t enough ambulances or crews to take people out of town. In addition, unless a hospital has access to a committed transfer ambulance, a transfer may take an ambulance out of community circulation for 2, 4, 8, or 12 hours. This is time that they won’t be able to respond to local emergencies. It was so bad during COVID-19 that it wasn’t uncommon for us to let more stable patients simply drive themselves rather than wait 18 hours for an ambulance.

The helicopter is not usually the right answer. It is a very costly way to transfer patients, often resulting in charges that start around $50,000. For an uninsured patient, this can be devastating and life altering. Furthermore, helicopters are dangerous even in the hands of the best pilots, and one should only risk those crews if absolutely unavoidable.

Patients who come to the ER and are transferred have already incurred great expense, and when transferred may incur another ER charge, in addition to the charge for transport. Not that money should be the chief concern, but it’s a hard reality for a lot of patients.

When patients are transferred far away it is very difficult for them to have the support of family members and friends, many of whom can’t take the time, or now afford the gasoline, to visit them. All too often transferred patients, once discharged, have no way to get back to their homes. And no way to follow up with the specialists they saw out of town.

Finally, there may well be no available beds in other facilities, consigning these patients to the care of emergency physicians for hours to days to weeks. We emergency physicians and nurses are excellent at acute care of short duration, but not at long-term care day after day. It’s easy for things to get missed as ambulances pour in and we manage airways and arrhythmias and all the rest.

I’m sympathetic to those who want to transfer and those in overwhelmed facilities who have to receive them. I’ve heard the exhaustion and anxiety in everyone’s voice — my own included.

Sometimes it’s a necessary thing, the transfer. But maybe we can take a step back and consider some of the repercussions. If we really care about our patients, and our colleagues, then we need to transfer not just because we can, but because we truly must.

Edwin Leap, MD, is an emergency physician who blogs at edwinleap.com, and is the author of The Practice Test and Life in Emergistan. You can read more of his writing on his Substack column, Life and Limb.