Need some advice or opinions

[Guest guest]

In a message dated 7/19/2007 7:59:18 P.M. Central Daylight Time,

ffto@... writes:

Question 1: Is this a violation of EMTALA laws since it is happening on the

hospital property and the hospital refuses to help?

I digress to the EMTLA brains of the List ala gandy etc.

Question 2: What would be the the ramifications and possible public opinion

if EMS refused to respond, especially if the news makes a big deal out of

" EMS refuses to help " ?

UGLY, UGY and just plain UGLY. Never piss off a guy that buys his ink by the

barrel is an old bastardization of a Harry Truman quote, take it to heart.

Question 3: Does EMS have the responsibility to respond?

Legally I'm not sure, morally I think yes.

Question 4: What would you do in this situation?

Answer the 9-1-1 call, treat and transfer care as appropriate. Write it up

and let the guys in the office worry about the billing issues.

Louis N. Molino, Sr., CET

FF/NREMT-B/FSI/EMSI

Owner and President of LNM Emergency Services Consulting Services (LNMECS)

Freelance Consultant/Trainer/Author/Journalist/Fire Protection Consultant

LNMolino@...

(Cell Phone)

(IFW/TFW/FSS Office)

(IFW/TFW/FSS Fax)

(Home Phone)

The comments contained in this E-mail are the opinions of the author and the

author alone. I in no way ever intend to speak for any person or

organization that I am in any way whatsoever involved or associated with unless

I

specifically state that I am doing so. Further this E-mail is intended only for

its

stated recipient and may contain private and or confidential materials

retransmission is strictly prohibited unless placed in the public domain by the

original author.

************************************** Get a sneak peek of the all-new AOL at

http://discover.aol.com/memed/aolcom30tour

[Guest guest]

I have a complex question for the great minds on this list.

You have a hospital that leases out a floor to a company that provides mental

geriatric (above 50 years of age) care.

They call EMS to respond for a patient for whatever reason (fall, seizure etc.)

and your unit responds and places the patient on the cot and goes down the

elevator to the first floor to the ER. Medicare will not pay because you did not

transport in the unit.

The hospital personnel refuse to go the floor to help out even though it is in

the hospital building.

EMS is not paid and neither provider will pay. Is this essentially giving away a

service that a city provides?

Question 1: Is this a violation of EMTALA laws since it is happening on the

hospital property and the hospital refuses to help?

Question 2: What would be the the ramifications and possible public opinion if

EMS refused to respond, especially if the news makes a big deal out of " EMS

refuses to help " ?

Question 3: Does EMS have the responsibility to respond?

Question 4: What would you do in this situation?

Thanks again

Don

[Guest guest]

Comments inline

Hatfield FF/EMT-P

>>EMS is not paid and neither provider will pay. Is this essentially giving away

a service that a city provides?

Yeah, and a waste of resources

>>Question 1: Is this a violation of EMTALA laws since it is happening on the

>>hospital property and the hospital refuses to help?

I was trying desperately to find a way where this would not be an EMTALA

violation only because I like to play devils advocate and start arguments

occasionally. This one escapes me. If it occured on hospital grounds, they are

required to complete certain assessments etc. Does that mean they have to go to

the floor and bring the patient to the ER? They may assume (dangerous as that

may be)that your service is responsible for that.....you have, after all, more

than created a precedent by responding to the falls, seizures etc. up to this

point.

>>Question 2: What would be the the ramifications and possible public >>opinion

if EMS refused to respond, especially if the news makes a big deal >>out of " EMS

refuses to help " ?

Lou said it best, ugly ugly ugly. Don't even do that.

>>Question 3: Does EMS have the responsibility to respond?

If you are dispatched, then you have a duty to act. Simple as that. If they are

calling you by phone, well that becomees tricky.

>>Question 4: What would you do in this situation?

Print out a copy of EMTALA, highlight the pertinent areas, and call a conference

with the administrator of the hospital. This presumes that it is your

responsibility, if you are NOT management, pass the buck and let them deal with

it. You keep going upstairs and picking them up until mgmt tells you different.

I trust that Gene and Wes will review my answers and make fun of me

accordingly.......

[Guest guest]

May want to check into posts for the Governor's EMS and Trauma Advisory

Council (GETAC) and send them a letter or email.

May be best not to take the patient out to your vehicle and do a few

donuts on the hospital's front lawn on the way to the ER, then see if

they call you again.

You may want to ask your attoney about writing a certified letter to the

hospital administrator and each member of the hospital board explaining

that your contract does not provide for transportation to the hospital

by other than motor vehicle. Naturally, review what your cantract does

say first. Provide an effective date for termination of the " free "

service and offer to contract for this extra service at a commercially

reasonable rate. Just a suggestion...

P. Osborn, Dallas, TX

>

> Comments inline

>

>

>

> Hatfield FF/EMT-P

>

>

> >>EMS is not paid and neither provider will pay. Is this essentially

giving away a service that a city provides?

>

>

> Yeah, and a waste of resources

>

>

> >>Question 1: Is this a violation of EMTALA laws since it is happening

on the >>hospital property and the hospital refuses to help?

>

>

> I was trying desperately to find a way where this would not be an

EMTALA violation only because I like to play devils advocate and start

arguments occasionally. This one escapes me. If it occured on hospital

grounds, they are required to complete certain assessments etc. Does

that mean they have to go to the floor and bring the patient to the ER?

They may assume (dangerous as that may be)that your service is

responsible for that.....you have, after all, more than created a

precedent by responding to the falls, seizures etc. up to this point.

>

>

>

> >>Question 2: What would be the the ramifications and possible public

>>opinion if EMS refused to respond, especially if the news makes a big

deal >>out of " EMS refuses to help " ?

>

>

> Lou said it best, ugly ugly ugly. Don't even do that.

>

>

>

> >>Question 3: Does EMS have the responsibility to respond?

>

>

>

> If you are dispatched, then you have a duty to act. Simple as that. If

they are calling you by phone, well that becomees tricky.

>

>

>

>

> >>Question 4: What would you do in this situation?

>

>

>

> Print out a copy of EMTALA, highlight the pertinent areas, and call a

conference with the administrator of the hospital. This presumes that it

is your responsibility, if you are NOT management, pass the buck and let

them deal with it. You keep going upstairs and picking them up until

mgmt tells you different.

>

>

>

>

> I trust that Gene and Wes will review my answers and make fun of me

accordingly.......

>

>

>

>

[Guest guest]

Let me throw in one point here...before walking in with our really big stick and

busting up bar stools and juke boxes...I would suggest having a meeting between

the agency head and the facility folks. Explain the entire situation. If

people other than nurse managers are involved, they have a BIG understanding of

the costs of healthcare and they respond very well.Â

Hospitals, (like all EMS agencies BTW...go ahead start smacking) are in the

healthcare business to make a profit (aka reserve, surplus, etc). They do very

little for free and once explained to them, have a decent understanding of the

impact to the pre-hospital provider. Working solutions with them would, in my

opinion, be much better than threats and certified letters to board's of

directors.Â

I can tell you from experience...when a BOD gets a certified letter, they call

the director and ask what the deal is. IF the director says " I never knew this

was even happening or an issue " then it is summarily left in their hands to

resolve and report back on...and, BTW, the letter sender is now seen in a less

favorable light than they would have been if they had worked through the

system. BOD's are not operational people...if they were...they would be doing

the day to day operations.

Sit down, meet with the folks. No resolution, take it higher in your

organization (i got the impression this is a municipal agency) get your City Mgr

and the Hospital Administrator involved next....then, if still no resolution,

take it to YOUR city council for discussion. This makes it public by default

and allows you to see what your elected officials feel is appropriate and what

is not....

Just some early morning thoughts from a foggy brain.

Dudley

Re: Need some advice or opinions

May want to check into posts for the Governor's EMS and Trauma Advisory

Council (GETAC) and send them a letter or email.

May be best not to take the patient out to your vehicle and do a few

donuts on the hospital's front lawn on the way to the ER, then see if

they call you again.

You may want to ask your attoney about writing a certified letter to the

hospital administrator and each member of the hospital board explaining

that your contract does not provide for transportation to the hospital

by other than motor vehicle. Naturally, review what your cantract does

say first. Provide an effective date for termination of the " free "

service and offer to contract for this extra service at a commercially

reasonable rate. Just a suggestion...

P. Osborn, Dallas, TX

>

> Comments inline

>

>

>

> Hatfield FF/EMT-P

>

>

> >>EMS is not paid and neither provider will pay. Is this essentially

giving away a service that a city provides?

>

>

> Yeah, and a waste of resources

>

>

> >>Question 1: Is this a violation of EMTALA laws since it is happening

on the >>hospital property and the hospital refuses to help?

>

>

> I was trying desperately to find a way where this would not be an

EMTALA violation only because I like to play devils advocate and start

arguments occasionally. This one escapes me. If it occured on hospital

grounds, they are required to complete certain assessments etc. Does

that mean they have to go to the floor and bring the patient to the ER?

They may assume (dangerous as that may be)that your service is

responsible for that.....you have, after all, more than created a

precedent by responding to the falls, seizures etc. up to this point.

>

>

>

> >>Question 2: What would be the the ramifications and possible public

>>opinion if EMS refused to respond, especially if the news makes a big

deal >>out of " EMS refuses to help " ?

>

>

> Lou said it best, ugly ugly ugly. Don't even do that.

>

>

>

> >>Question 3: Does EMS have the responsibility to respond?

>

>

>

> If you are dispatched, then you have a duty to act. Simple as that. If

they are calling you by phone, well that becomees tricky.

>

>

>

>

> >>Question 4: What would you do in this situation?

>

>

>

> Print out a copy of EMTALA, highlight the pertinent areas, and call a

conference with the administrator of the hospital. This presumes that it

is your responsibility, if you are NOT management, pass the buck and let

them deal with it. You keep going upstairs and picking them up until

mgmt tells you different.

>

>

>

>

> I trust that Gene and Wes will review my answers and make fun of me

accordingly.......

>

>

>

>

[Guest guest]

Don,

I know of one agency that routinely picked up patients at a skilled nursing

facility that was located a very short walk across a parking lot from the

hospital ER. It was far more sensible to roll the stretcher down the sidewalk.

Unfortunately, CMS did not see it that way. Each patient had to be loaded into

the unit. The parking lot was just wide enough to be able to pull the ambulance

out, cut the wheel, then back it up to the ER door. For almost to two years

this procedure was followed, until the billing agency that was involved managed

to get someone from CMS to physically come to the facility and evaluate. They

were given some sort of dispensation, and now the patients once again get rolled

down the sidewalk, and the provider gets paid. This was probably a miracle, but

it may be worth pursuing.

Vernon Gresham

City of Ganado

Need some advice or opinions

I have a complex question for the great minds on this list.

You have a hospital that leases out a floor to a company that provides mental

geriatric (above 50 years of age) care.

They call EMS to respond for a patient for whatever reason (fall, seizure

etc.) and your unit responds and places the patient on the cot and goes down the

elevator to the first floor to the ER. Medicare will not pay because you did not

transport in the unit.

The hospital personnel refuse to go the floor to help out even though it is in

the hospital building.

EMS is not paid and neither provider will pay. Is this essentially giving away

a service that a city provides?

Question 1: Is this a violation of EMTALA laws since it is happening on the

hospital property and the hospital refuses to help?

Question 2: What would be the the ramifications and possible public opinion if

EMS refused to respond, especially if the news makes a big deal out of " EMS

refuses to help " ?

Question 3: Does EMS have the responsibility to respond?

Question 4: What would you do in this situation?

Thanks again

Don

[Guest guest]

In a message dated 7/20/2007 3:22:55 P.M. Central Daylight Time,

jyovanovitch@... writes:

EMTALA states that a hospital with and Emergency Department is responsible

for ALL medical emergencies that not only happen on their property, but also

occur within 250 yards of the property. (This would also mean vertical.)

See I learned something new today.

Louis N. Molino, Sr., CET

FF/NREMT-B/FSI/EMSI

Owner and President of LNM Emergency Services Consulting Services (LNMECS)

Freelance Consultant/Trainer/Author/Journalist/Fire Protection Consultant

LNMolino@...

(Cell Phone)

(IFW/TFW/FSS Office)

(IFW/TFW/FSS Fax)

(Home Phone)

The comments contained in this E-mail are the opinions of the author and the

author alone. I in no way ever intend to speak for any person or

organization that I am in any way whatsoever involved or associated with unless

I

specifically state that I am doing so. Further this E-mail is intended only for

its

stated recipient and may contain private and or confidential materials

retransmission is strictly prohibited unless placed in the public domain by the

original author.

************************************** Get a sneak peek of the all-new AOL at

http://discover.aol.com/memed/aolcom30tour

[Guest guest]

As says, this is a good reference. You can get to the law itself from

there if you have enough NoDoze to stay awake while you read it. LOL .

http://www.emtala.com/

I am not sure that there is an EMTALA violation because of this portion of

the statute:

" Hospital property means the entire main hospital campus as defined in §

413.65( of this chapter, including the parking lot, sidewalk, and driveway,

but

excluding other areas or structures of the hospital’s main building that are

not part of the hospital, such as physician offices, rural health centers,

skilled nursing facilities, or other entities that participate separately under

Medicare, or restaurants, shops, or other nonmedical facilities. "

There is one sure way to find out, and that is to call the folks at The

Office of the Inspector General of HHS (OIG) and ask them. They have a whole

compendium of rules for enforcement which are sometimes not clear even to them.

I cannot imagine why the hospital called for an ambulance, but since it did,

EMS had the duty to respond. A failure or refusal to respond could have

subjected them to liability, but not under EMTALA, since EMS is not covered

under

EMTALA. Only hospitals are.

I see no reason that the 250 yard rule would not apply vertically. The only

questionable item is that the floor in question is a separate entity, with

separate Medicare funding.

Gene Gandy, JD, LP

In a message dated 7/20/07 1:23:20 PM, jyovanovitch@...

writes:

>

>

> EMTALA states that a hospital with and Emergency Department is responsible

> for ALL medical emergencies that not only happen on their property, but also

> occur within 250 yards of the property. (This would also mean vertical.)

>

> When the law came out (circa 2000), I was employed by a hospital. We had to

> write procedures for the ED staff to respond outside the hospital if

> something occurred and we were unable to get ambulance assistance. We also

> had a " mutual aid " agreement with the pediatric hospital next door.

> Effectively, it was 250 yards around BOTH facilities with ours responding to

> adults and theirs responding to Pediatrics.

>

> God help if they ever had to actually respond outside the nice comfortable

> building.

>

> You can find out more at www.emtala.com if the site come back up. Mayby

> Gene had a copy that he could send out or Reader's Digest for us.

>

> Lasher Yovanovitch, Sr

>

> Firefighter/ Firefighter/<w

>

>

[Guest guest]

In a message dated 7/20/2007 6:32:27 P.M. Central Daylight Time,

wegandy1938@... writes:

I see no reason that the 250 yard rule would not apply vertically. The

only

questionable item is that the floor in question is a separate entity, with

separate Medicare funding.

Hence again we see an example of a law that is as clear as mud on a rainy

day!

Louis N. Molino, Sr., CET

FF/NREMT-B/FSI/EMSI

Owner and President of LNM Emergency Services Consulting Services (LNMECS)

Freelance Consultant/Trainer/Author/Journalist/Fire Protection Consultant

LNMolino@...

(Cell Phone)

(IFW/TFW/FSS Office)

(IFW/TFW/FSS Fax)

(Home Phone)

The comments contained in this E-mail are the opinions of the author and the

author alone. I in no way ever intend to speak for any person or

organization that I am in any way whatsoever involved or associated with unless

I

specifically state that I am doing so. Further this E-mail is intended only for

its

stated recipient and may contain private and or confidential materials

retransmission is strictly prohibited unless placed in the public domain by the

original author.

************************************** Get a sneak peek of the all-new AOL at

http://discover.aol.com/memed/aolcom30tour

[Guest guest]

As far as I can tell, the 2004 revisions are the latest, and they clearly

exclude a skilled nursing facility on campus if it is operated under separate

Medicare certification.

I think there would need to be more specificity about the status of the

" leased " entity before one could come to a definitive conclusion.

I think that provision trumps the 250 yard rule, or at least that's the way

it reads in context to me.

Also, I need to make one clarification about my last post. EMTALA does not

apply to ambulance services unless they are operated by the hospital. And

then, if they are operated under a regional EMS plan which provides for

transport to the most appropriate hospital, then they are allowed to transport

there,

as in a Level I trauma center or a cardiac or stroke center rather than to the

owner facility.

Gene

>

>

>

> In a message dated 7/20/2007 6:32:27 P.M. Central Daylight Time,

> wegandy1938@wegandy writes:

>

> I see no reason that the 250 yard rule would not apply vertically. The

> only

> questionable item is that the floor in question is a separate entity, with

> separate Medicare funding.

>

> Hence again we see an example of a law that is as clear as mud on a rainy

> day!

>

> Louis N. Molino, Sr., CET

> FF/NREMT-B/FSI/ FF/

> Owner and President of LNM Emergency Services Consulting Services (LNMECS)

> Freelance Consultant/Trainer/ Freelance Cons Freelance Consultant/Traine

>

> LNMolino@...

>

> (Cell Phone)

> (IFW/TFW/FSS Office)

> (IFW/TFW/FSS Fax)

> (Home Phone)

>

> The comments contained in this E-mail are the opinions of the author and the

> author alone. I in no way ever intend to speak for any person or

> organization that I am in any way whatsoever involved or associated with

> unless I

> specifically state that I am doing so. Further this E-mail is intended only

> for its

> stated recipient and may contain private and or confidential materials

> retransmission is strictly prohibited unless placed in the public domain by

> the

> original author.

>

> ************ ******** ******** ************<wbr>*********<wbr>*********<wbr>

> **

> http://discover.http://discovehttp://disco

>

>

[Guest guest]

In 2006 the American Hospital Association (AHA) asked the government for

clarification regarding the appropriateness of a hospital calling EMS to a

location owned by the hospital where EMS could offer better and more immediat

care

than a responding in-hospital team. Here is the substance of a portion of its

request, from an AHA website:

AHA Comments - The specificity of the protocol requirements has the potential

to interfere with what would otherwise be an appropriate response by a

hospital.

" The regulations should explicitly recognize the appropriateness of using

emergency medical services (EMS) personnel and calling " 9-1-1 " or other

designated emergency number. " Current experience demonstrates that the public

will

choose an emergency department over another type of facility when the individual

believes he or she has an emergency medical condition. It is the exception

when such an individual will present to an off-campus department. The few

examples we have identified where an individual presented to an off-campus

department

with an emergency medical condition involved chest pain or a cardiac

condition. In those exceptional circumstances there should be no ambiguity that

calling EMS is an appropriate response. Many of these departments will be

specialty

clinics and may be part of specialty hospitals. The suggestion that a hospital

dispatch staff to the department and the preamble discussion regarding the

use of EMS could be interpreted as a bias against the use of EMS. The

regulations should also clarify that the requirement for direct contact between

the

off-campus department and emergency personnel at the main hospital campus does

not

have to occur before other appropriate action is taken. Making such contact

should not delay responding to an individual. "

>

>

>

> In a message dated 7/20/2007 6:32:27 P.M. Central Daylight Time,

> wegandy1938@wegandy writes:

>

> I see no reason that the 250 yard rule would not apply vertically. The

> only

> questionable item is that the floor in question is a separate entity, with

> separate Medicare funding.

>

> Hence again we see an example of a law that is as clear as mud on a rainy

> day!

>

> Louis N. Molino, Sr., CET

> FF/NREMT-B/FSI/ FF/

> Owner and President of LNM Emergency Services Consulting Services (LNMECS)

> Freelance Consultant/Trainer/ Freelance Cons Freelance Consultant/Traine

>

> LNMolino@...

>

> (Cell Phone)

> (IFW/TFW/FSS Office)

> (IFW/TFW/FSS Fax)

> (Home Phone)

>

> The comments contained in this E-mail are the opinions of the author and the

> author alone. I in no way ever intend to speak for any person or

> organization that I am in any way whatsoever involved or associated with

> unless I

> specifically state that I am doing so. Further this E-mail is intended only

> for its

> stated recipient and may contain private and or confidential materials

> retransmission is strictly prohibited unless placed in the public domain by

> the

> original author.

>

> ************ ******** ******** ************<wbr>*********<wbr>*********<wbr>

> **

> http://discover.http://discovehttp://disco

>

>

[Guest guest]

EMTALA states that a hospital with and Emergency Department is responsible

for ALL medical emergencies that not only happen on their property, but also

occur within 250 yards of the property. (This would also mean vertical.)

When the law came out (circa 2000), I was employed by a hospital. We had to

write procedures for the ED staff to respond outside the hospital if

something occurred and we were unable to get ambulance assistance. We also

had a " mutual aid " agreement with the pediatric hospital next door.

Effectively, it was 250 yards around BOTH facilities with ours responding to

adults and theirs responding to Pediatrics.

God help if they ever had to actually respond outside the nice comfortable

building.

You can find out more at www.emtala.com if the site come back up. Mayby

Gene had a copy that he could send out or Reader's Digest for us.

Lasher Yovanovitch, Sr

Firefighter/NREMT-Paramedic

[Guest guest]

You are partially correct. The rule did not come from a court case. It

was promulgated after a 1998 incident in Chicago in which a teenage male was

shot in a playground near a hospital, Ravenswood Hospital. He was brought to

an

alleyway near the ER, and the ER was contacted but refused to send anyone out

to see about him. EMS was called. He died.

It was determined that under the existing rules there was no EMTALA

violation. The Clinton administration then added the " 250 yard rule " which is

found

in the Code of Federal Regulations.

The 250-yard rule comes from the definition of " Campus " found at 42 CFR

413.65:

" Campus means the physical area immediately adjacent to the provider’s main

buildings, other areas and structures that are not strictly contiguous to the

main buildings but are located within 250 yards of the main buildings, and any

other areas determined on an individual case basis, by the HCFA regional

office, to be part of the provider’s campus.

Gene Gandy, JD, LP

>

> The 250 yard rule was established by a court case. I cannot cite it at this

> time but it was an Illinois case if I recall correctly. It was never a part

> of the original EMTALA law nor was it amended into it.

>

> AJL

>

>

[Guest guest]

This case seems to be an anomaly. As stated in various commentaries,

there's no indication that the court considered the 250 yard rule. One wonders

whether or not the correct arguments were presented.

I get a bad feeling about the lawyers. They might have been better off to

stick with a common law claim of negligence in the state court than going into

federal court on an EMTALA violation.

The case should have been appealed. I cannot find any information showing

that it was appealed. However, if the proper arguments were not presented to

the court, an appeal might not succeed, although my reading of the 9th Circuit

is that it would probably have found a way around it.

Choosing the right lawyers is critical, just as choosing the right doctors

is.

Gene G.

>

> More info on the " 250 yard rule "

>

> From Frew's site:

>

> California Court Dodges 250-Yard Rule

>

> A federal court in California found a plaintiff who fell and

> was injured in the parking lot of a medical center had no

> claim under the Emergency Medical Treatment and Labor Act

> (EMTALA) against the hospital.

>

> In reaching the conclusion, there is no indication that

> the Court considered the CMS Regulation that added parking

> lots and similar locations within 250 yards of the hospital

> to the definition of having presented to the hospital for

> EMTALA purposes.

>

> The court explained its decision under the interpretation

> that EMTALA is a statute aimed at prohibiting patient

> dumping and once the plaintiff was taken to the medical

> center she received treatment and was not " dumped " in any

> way, the court said.

>

> The court further held that EMTALA contains no requirement

> that a medical center use its own personnel to transport

> a patient injured on its premises to the emergency

> department.

>

> Published accounts indicate Plaintiff Addiego was

> taken by her daughter to the California Pacific Medical

> Center (CPMC) for an appointment. As plaintiff exited her

> car in CPMC's parking garage, she fell and broke her hip.

>

> Although they were located about thirty yards from CPMC's

> emergency department, the parking attendant instead called

> the security department who refused plaintiff's request for

> immediate medical attention from the emergency department.

> Instead, security called 911. After plaintiff had been

> lying on the ground for nearly an hour, an ambulance came

> and transported plaintiff thirty yards to CPMC's emergency

> department.

>

> Plaintiff sued CPMC alleging the delay made her injuries

> worse and claiming premises liability and personal injury.

> Plaintiff also filed a separate action adding the City and

> County of San Francisco as a defendant and alleging that

> CPMC violated EMTALA by refusing to transport her to the

> emergency department, and instead requiring that the San

> Francisco Fire Department do so.

>

> The situation is strikingly similar to the incident at

> Ravenswood Hospital in Chicago where a hospital ED refused

> to assist a teenager who had been shot and lay just a short

> distance from the ED entrance. Chicago Fire EMS did not

> respond because it was an incident at a hospital and

> interpret ted the call as a transfer request. Chicago police,

> reportedly frustrated by the stand-off between the hospital

> and EMS, deviated from departmental rules and moved the

> child to the hospital ED just yards away. The child,

> however, died from loss of blood attributed to the delay

> in care.

>

> In response to this Chicago event, CMS added a definition in

> its Out-Patient Prospective Payment regulations defining the

> area of 250 yards around the hospital, including access

> areas and hospital parking areas, to be " presenting to the

> hospital " for EMTALA compliance rules. The rules also

> require the hospital to provide a response to the patient

> in addition to calling 9-1-1.

>

> While the decision is likely to influence litigation cases

> arising in the Northern District of California, it is

> unlikely to influence CMS enforcement of the 250 yard

> requirements of the OPPS regulation under EMTALA.

>

> Never-the-less, one wonders whether the court was provided

> information on the 250-yard rule and ignored it, or whether

> the attorneys' for the patient failed to present the rule

> that was specifically intended to prevent incidents like the

> one described. In either case, someone screwed up.

>

> The patient is fortunate that they fell in California, and

> not northern Michigan, or they might have frozen to death

> awaiting the delayed EMS response while hospital personnel

> ignored a seriously injured patient within view of the

> ED entrance.

>

> Addiego v. City and County of San Francisco, No. C 05-04819

> CRB (N.D. Cal. Feb. 17, 2006).

>

>

[Guest guest]

One other thing needs to be said. Though EMS was called, the Chicago FD

refused to send a truck because the patient was on hospital property. Finally,

the police, seeing that a stand-off was in progress between the hospital and

EMS, took the patient inside where he died from blood loss.

Gene

>

> Thanks for the clarification, i stand corrected.

>

> AJL

>

>

> >

> > You are partially correct. The rule did not come from a court case. It

> > was promulgated after a 1998 incident in Chicago in which a teenage male

> > was

> > shot in a playground near a hospital, Ravenswood Hospital. He was brought

> > to an

> > alleyway near the ER, and the ER was contacted but refused to send anyone

> > out

> > to see about him. EMS was called. He died.

> >

> > It was determined that under the existing rules there was no EMTALA

> > violation. The Clinton administration then added the " 250 yard rule " which

> > is found

> > in the Code of Federal Regulations.

> >

> > The 250-yard rule comes from the definition of " Campus " found at 42 CFR

> > 413.65:

> >

> > " Campus means the physical area immediately adjacent to the provider's

> > main

> > buildings, other areas and structures that are not strictly contiguous to

> > the

> > main buildings but are located within 250 yards of the main buildings, and

> > any

> > other areas determined on an individual case basis, by the HCFA regional

> > office, to be part of the provider's campus.

> >

> > Gene Gandy, JD, LP

> >

> > In a message dated 7/20/07 5:30:23 PM, ajl442@...<ajl442%40gmail.ajl>

> writes:

> >

> > >

> > > The 250 yard rule was established by a court case. I cannot cite it at

> > this

> > > time but it was an Illinois case if I recall correctly. It was never a

> > part

> > > of the original EMTALA law nor was it amended into it.

> > >

> > > AJL

> > >

> > >

[Guest guest]

The 250 yard rule was established by a court case. I cannot cite it at this

time but it was an Illinois case if I recall correctly. It was never a part

of the original EMTALA law nor was it amended into it.

AJL

[Guest guest]

More info on the " 250 yard rule "

From Frew's site:

California Court Dodges 250-Yard Rule

A federal court in California found a plaintiff who fell and

was injured in the parking lot of a medical center had no

claim under the Emergency Medical Treatment and Labor Act

(EMTALA) against the hospital.

In reaching the conclusion, there is no indication that

the Court considered the CMS Regulation that added parking

lots and similar locations within 250 yards of the hospital

to the definition of having presented to the hospital for

EMTALA purposes.

The court explained its decision under the interpretation

that EMTALA is a statute aimed at prohibiting patient

dumping and once the plaintiff was taken to the medical

center she received treatment and was not " dumped " in any

way, the court said.

The court further held that EMTALA contains no requirement

that a medical center use its own personnel to transport

a patient injured on its premises to the emergency

department.

Published accounts indicate Plaintiff Addiego was

taken by her daughter to the California Pacific Medical

Center (CPMC) for an appointment. As plaintiff exited her

car in CPMC's parking garage, she fell and broke her hip.

Although they were located about thirty yards from CPMC's

emergency department, the parking attendant instead called

the security department who refused plaintiff's request for

immediate medical attention from the emergency department.

Instead, security called 911. After plaintiff had been

lying on the ground for nearly an hour, an ambulance came

and transported plaintiff thirty yards to CPMC's emergency

department.

Plaintiff sued CPMC alleging the delay made her injuries

worse and claiming premises liability and personal injury.

Plaintiff also filed a separate action adding the City and

County of San Francisco as a defendant and alleging that

CPMC violated EMTALA by refusing to transport her to the

emergency department, and instead requiring that the San

Francisco Fire Department do so.

The situation is strikingly similar to the incident at

Ravenswood Hospital in Chicago where a hospital ED refused

to assist a teenager who had been shot and lay just a short

distance from the ED entrance. Chicago Fire EMS did not

respond because it was an incident at a hospital and

interpret ted the call as a transfer request. Chicago police,

reportedly frustrated by the stand-off between the hospital

and EMS, deviated from departmental rules and moved the

child to the hospital ED just yards away. The child,

however, died from loss of blood attributed to the delay

in care.

In response to this Chicago event, CMS added a definition in

its Out-Patient Prospective Payment regulations defining the

area of 250 yards around the hospital, including access

areas and hospital parking areas, to be " presenting to the

hospital " for EMTALA compliance rules. The rules also

require the hospital to provide a response to the patient

in addition to calling 9-1-1.

While the decision is likely to influence litigation cases

arising in the Northern District of California, it is

unlikely to influence CMS enforcement of the 250 yard

requirements of the OPPS regulation under EMTALA.

Never-the-less, one wonders whether the court was provided

information on the 250-yard rule and ignored it, or whether

the attorneys' for the patient failed to present the rule

that was specifically intended to prevent incidents like the

one described. In either case, someone screwed up.

The patient is fortunate that they fell in California, and

not northern Michigan, or they might have frozen to death

awaiting the delayed EMS response while hospital personnel

ignored a seriously injured patient within view of the

ED entrance.

Addiego v. City and County of San Francisco, No. C 05-04819

CRB (N.D. Cal. Feb. 17, 2006).

[Guest guest]

Thanks for the clarification, i stand corrected.

AJL

>

> You are partially correct. The rule did not come from a court case. It

> was promulgated after a 1998 incident in Chicago in which a teenage male

> was

> shot in a playground near a hospital, Ravenswood Hospital. He was brought

> to an

> alleyway near the ER, and the ER was contacted but refused to send anyone

> out

> to see about him. EMS was called. He died.

>

> It was determined that under the existing rules there was no EMTALA

> violation. The Clinton administration then added the " 250 yard rule " which

> is found

> in the Code of Federal Regulations.

>

> The 250-yard rule comes from the definition of " Campus " found at 42 CFR

> 413.65:

>

> " Campus means the physical area immediately adjacent to the provider's

> main

> buildings, other areas and structures that are not strictly contiguous to

> the

> main buildings but are located within 250 yards of the main buildings, and

> any

> other areas determined on an individual case basis, by the HCFA regional

> office, to be part of the provider's campus.

>

> Gene Gandy, JD, LP

>

> In a message dated 7/20/07 5:30:23 PM,

ajl442@...<ajl442%40gmail.com>writes:

>

> >

> > The 250 yard rule was established by a court case. I cannot cite it at

> this

> > time but it was an Illinois case if I recall correctly. It was never a

> part

> > of the original EMTALA law nor was it amended into it.

> >

> > AJL

> >

> >

[Guest guest]

What ?????????????????????????????????????????????????????????????????

Alan Lambert wrote: More info on the " 250 yard rule "

From Frew's site:

California Court Dodges 250-Yard Rule

A federal court in California found a plaintiff who fell and

was injured in the parking lot of a medical center had no

claim under the Emergency Medical Treatment and Labor Act

(EMTALA) against the hospital.

In reaching the conclusion, there is no indication that

the Court considered the CMS Regulation that added parking

lots and similar locations within 250 yards of the hospital

to the definition of having presented to the hospital for

EMTALA purposes.

The court explained its decision under the interpretation

that EMTALA is a statute aimed at prohibiting patient

dumping and once the plaintiff was taken to the medical

center she received treatment and was not " dumped " in any

way, the court said.

The court further held that EMTALA contains no requirement

that a medical center use its own personnel to transport

a patient injured on its premises to the emergency

department.

Published accounts indicate Plaintiff Addiego was

taken by her daughter to the California Pacific Medical

Center (CPMC) for an appointment. As plaintiff exited her

car in CPMC's parking garage, she fell and broke her hip.

Although they were located about thirty yards from CPMC's

emergency department, the parking attendant instead called

the security department who refused plaintiff's request for

immediate medical attention from the emergency department.

Instead, security called 911. After plaintiff had been

lying on the ground for nearly an hour, an ambulance came

and transported plaintiff thirty yards to CPMC's emergency

department.

Plaintiff sued CPMC alleging the delay made her injuries

worse and claiming premises liability and personal injury.

Plaintiff also filed a separate action adding the City and

County of San Francisco as a defendant and alleging that

CPMC violated EMTALA by refusing to transport her to the

emergency department, and instead requiring that the San

Francisco Fire Department do so.

The situation is strikingly similar to the incident at

Ravenswood Hospital in Chicago where a hospital ED refused

to assist a teenager who had been shot and lay just a short

distance from the ED entrance. Chicago Fire EMS did not

respond because it was an incident at a hospital and

interpret ted the call as a transfer request. Chicago police,

reportedly frustrated by the stand-off between the hospital

and EMS, deviated from departmental rules and moved the

child to the hospital ED just yards away. The child,

however, died from loss of blood attributed to the delay

in care.

In response to this Chicago event, CMS added a definition in

its Out-Patient Prospective Payment regulations defining the

area of 250 yards around the hospital, including access

areas and hospital parking areas, to be " presenting to the

hospital " for EMTALA compliance rules. The rules also

require the hospital to provide a response to the patient

in addition to calling 9-1-1.

While the decision is likely to influence litigation cases

arising in the Northern District of California, it is

unlikely to influence CMS enforcement of the 250 yard

requirements of the OPPS regulation under EMTALA.

Never-the-less, one wonders whether the court was provided

information on the 250-yard rule and ignored it, or whether

the attorneys' for the patient failed to present the rule

that was specifically intended to prevent incidents like the

one described. In either case, someone screwed up.

The patient is fortunate that they fell in California, and

not northern Michigan, or they might have frozen to death

awaiting the delayed EMS response while hospital personnel

ignored a seriously injured patient within view of the

ED entrance.

Addiego v. City and County of San Francisco, No. C 05-04819

CRB (N.D. Cal. Feb. 17, 2006).

[Guest guest]

What ????????????????????????????????????????????????????????????????????

Alan Lambert wrote: More info on the " 250 yard rule "

From Frew's site:

California Court Dodges 250-Yard Rule

A federal court in California found a plaintiff who fell and

was injured in the parking lot of a medical center had no

claim under the Emergency Medical Treatment and Labor Act

(EMTALA) against the hospital.

In reaching the conclusion, there is no indication that

the Court considered the CMS Regulation that added parking

lots and similar locations within 250 yards of the hospital

to the definition of having presented to the hospital for

EMTALA purposes.

The court explained its decision under the interpretation

that EMTALA is a statute aimed at prohibiting patient

dumping and once the plaintiff was taken to the medical

center she received treatment and was not " dumped " in any

way, the court said.

The court further held that EMTALA contains no requirement

that a medical center use its own personnel to transport

a patient injured on its premises to the emergency

department.

Published accounts indicate Plaintiff Addiego was

taken by her daughter to the California Pacific Medical

Center (CPMC) for an appointment. As plaintiff exited her

car in CPMC's parking garage, she fell and broke her hip.

Although they were located about thirty yards from CPMC's

emergency department, the parking attendant instead called

the security department who refused plaintiff's request for

immediate medical attention from the emergency department.

Instead, security called 911. After plaintiff had been

lying on the ground for nearly an hour, an ambulance came

and transported plaintiff thirty yards to CPMC's emergency

department.

Plaintiff sued CPMC alleging the delay made her injuries

worse and claiming premises liability and personal injury.

Plaintiff also filed a separate action adding the City and

County of San Francisco as a defendant and alleging that

CPMC violated EMTALA by refusing to transport her to the

emergency department, and instead requiring that the San

Francisco Fire Department do so.

The situation is strikingly similar to the incident at

Ravenswood Hospital in Chicago where a hospital ED refused

to assist a teenager who had been shot and lay just a short

distance from the ED entrance. Chicago Fire EMS did not

respond because it was an incident at a hospital and

interpret ted the call as a transfer request. Chicago police,

reportedly frustrated by the stand-off between the hospital

and EMS, deviated from departmental rules and moved the

child to the hospital ED just yards away. The child,

however, died from loss of blood attributed to the delay

in care.

In response to this Chicago event, CMS added a definition in

its Out-Patient Prospective Payment regulations defining the

area of 250 yards around the hospital, including access

areas and hospital parking areas, to be " presenting to the

hospital " for EMTALA compliance rules. The rules also

require the hospital to provide a response to the patient

in addition to calling 9-1-1.

While the decision is likely to influence litigation cases

arising in the Northern District of California, it is

unlikely to influence CMS enforcement of the 250 yard

requirements of the OPPS regulation under EMTALA.

Never-the-less, one wonders whether the court was provided

information on the 250-yard rule and ignored it, or whether

the attorneys' for the patient failed to present the rule

that was specifically intended to prevent incidents like the

one described. In either case, someone screwed up.

The patient is fortunate that they fell in California, and

not northern Michigan, or they might have frozen to death

awaiting the delayed EMS response while hospital personnel

ignored a seriously injured patient within view of the

ED entrance.

Addiego v. City and County of San Francisco, No. C 05-04819

CRB (N.D. Cal. Feb. 17, 2006).

[Guest guest]

Learning Medic:

This one sounds like it may be appealed. You may not hear the last word in this

case. I am familiar with the hospital in question as once worked in San

Francisco. I am also familiar with the court it was presented in.

Be confident an appeal is coming. Regards, rabbiems

Re: Re: Need some advice or opinions

What ????????????????????????????????????????????????????????????????????

Alan Lambert wrote: More info on the " 250 yard rule "

From Frew's site:

California Court Dodges 250-Yard Rule

A federal court in California found a plaintiff who fell and

was injured in the parking lot of a medical center had no

claim under the Emergency Medical Treatment and Labor Act

(EMTALA) against the hospital.

In reaching the conclusion, there is no indication that

the Court considered the CMS Regulation that added parking

lots and similar locations within 250 yards of the hospital

to the definition of having presented to the hospital for

EMTALA purposes.

The court explained its decision under the interpretation

that EMTALA is a statute aimed at prohibiting patient

dumping and once the plaintiff was taken to the medical

center she received treatment and was not " dumped " in any

way, the court said.

The court further held that EMTALA contains no requirement

that a medical center use its own personnel to transport

a patient injured on its premises to the emergency

department.

Published accounts indicate Plaintiff Addiego was

taken by her daughter to the California Pacific Medical

Center (CPMC) for an appointment. As plaintiff exited her

car in CPMC's parking garage, she fell and broke her hip.

Although they were located about thirty yards from CPMC's

emergency department, the parking attendant instead called

the security department who refused plaintiff's request for

immediate medical attention from the emergency department.

Instead, security called 911. After plaintiff had been

lying on the ground for nearly an hour, an ambulance came

and transported plaintiff thirty yards to CPMC's emergency

department.

Plaintiff sued CPMC alleging the delay made her injuries

worse and claiming premises liability and personal injury.

Plaintiff also filed a separate action adding the City and

County of San Francisco as a defendant and alleging that

CPMC violated EMTALA by refusing to transport her to the

emergency department, and instead requiring that the San

Francisco Fire Department do so.

The situation is strikingly similar to the incident at

Ravenswood Hospital in Chicago where a hospital ED refused

to assist a teenager who had been shot and lay just a short

distance from the ED entrance. Chicago Fire EMS did not

respond because it was an incident at a hospital and

interpret ted the call as a transfer request. Chicago police,

reportedly frustrated by the stand-off between the hospital

and EMS, deviated from departmental rules and moved the

child to the hospital ED just yards away. The child,

however, died from loss of blood attributed to the delay

in care.

In response to this Chicago event, CMS added a definition in

its Out-Patient Prospective Payment regulations defining the

area of 250 yards around the hospital, including access

areas and hospital parking areas, to be " presenting to the

hospital " for EMTALA compliance rules. The rules also

require the hospital to provide a response to the patient

in addition to calling 9-1-1.

While the decision is likely to influence litigation cases

arising in the Northern District of California, it is

unlikely to influence CMS enforcement of the 250 yard

requirements of the OPPS regulation under EMTALA.

Never-the-less, one wonders whether the court was provided

information on the 250-yard rule and ignored it, or whether

the attorneys' for the patient failed to present the rule

that was specifically intended to prevent incidents like the

one described. In either case, someone screwed up.

The patient is fortunate that they fell in California, and

not northern Michigan, or they might have frozen to death

awaiting the delayed EMS response while hospital personnel

ignored a seriously injured patient within view of the

ED entrance.

Addiego v. City and County of San Francisco, No. C 05-04819

CRB (N.D. Cal. Feb. 17, 2006).

[Guest guest]

Thank you---and-----Shalom !

" rabbiems@... " wrote: Learning Medic:

This one sounds like it may be appealed. You may not hear the last word in this

case. I am familiar with the hospital in question as once worked in San

Francisco. I am also familiar with the court it was presented in.

Be confident an appeal is coming. Regards, rabbiems

Re: Re: Need some advice or opinions

What ????????????????????????????????????????????????????????????????????

Alan Lambert wrote: More info on the " 250 yard rule "

From Frew's site:

California Court Dodges 250-Yard Rule

A federal court in California found a plaintiff who fell and

was injured in the parking lot of a medical center had no

claim under the Emergency Medical Treatment and Labor Act

(EMTALA) against the hospital.

In reaching the conclusion, there is no indication that

the Court considered the CMS Regulation that added parking

lots and similar locations within 250 yards of the hospital

to the definition of having presented to the hospital for

EMTALA purposes.

The court explained its decision under the interpretation

that EMTALA is a statute aimed at prohibiting patient

dumping and once the plaintiff was taken to the medical

center she received treatment and was not " dumped " in any

way, the court said.

The court further held that EMTALA contains no requirement

that a medical center use its own personnel to transport

a patient injured on its premises to the emergency

department.

Published accounts indicate Plaintiff Addiego was

taken by her daughter to the California Pacific Medical

Center (CPMC) for an appointment. As plaintiff exited her

car in CPMC's parking garage, she fell and broke her hip.

Although they were located about thirty yards from CPMC's

emergency department, the parking attendant instead called

the security department who refused plaintiff's request for

immediate medical attention from the emergency department.

Instead, security called 911. After plaintiff had been

lying on the ground for nearly an hour, an ambulance came

and transported plaintiff thirty yards to CPMC's emergency

department.

Plaintiff sued CPMC alleging the delay made her injuries

worse and claiming premises liability and personal injury.

Plaintiff also filed a separate action adding the City and

County of San Francisco as a defendant and alleging that

CPMC violated EMTALA by refusing to transport her to the

emergency department, and instead requiring that the San

Francisco Fire Department do so.

The situation is strikingly similar to the incident at

Ravenswood Hospital in Chicago where a hospital ED refused

to assist a teenager who had been shot and lay just a short

distance from the ED entrance. Chicago Fire EMS did not

respond because it was an incident at a hospital and

interpret ted the call as a transfer request. Chicago police,

reportedly frustrated by the stand-off between the hospital

and EMS, deviated from departmental rules and moved the

child to the hospital ED just yards away. The child,

however, died from loss of blood attributed to the delay

in care.

In response to this Chicago event, CMS added a definition in

its Out-Patient Prospective Payment regulations defining the

area of 250 yards around the hospital, including access

areas and hospital parking areas, to be " presenting to the

hospital " for EMTALA compliance rules. The rules also

require the hospital to provide a response to the patient

in addition to calling 9-1-1.

While the decision is likely to influence litigation cases

arising in the Northern District of California, it is

unlikely to influence CMS enforcement of the 250 yard

requirements of the OPPS regulation under EMTALA.

Never-the-less, one wonders whether the court was provided

information on the 250-yard rule and ignored it, or whether

the attorneys' for the patient failed to present the rule

that was specifically intended to prevent incidents like the

one described. In either case, someone screwed up.

The patient is fortunate that they fell in California, and

not northern Michigan, or they might have frozen to death

awaiting the delayed EMS response while hospital personnel

ignored a seriously injured patient within view of the

ED entrance.

Addiego v. City and County of San Francisco, No. C 05-04819

CRB (N.D. Cal. Feb. 17, 2006).

[Guest guest]

I would not rely on this case as precedent for the following reasons:

1. There is no evidence that the 250 yard rule was " plead " before the

court, and therefore the court didn't consider it.

2. This was a civil suit against the hospital by a patient, not an

administrative proceeding by CMS against the hospital. CMS can still fine the

hospital and physician.

3. As you correctly say, this would not be precedent in any but the

Northern Dist of CA, and even there, it is not binding precedent, since all the

judges at the District Court level there are equal and not bound by each other's

opinions, although the opinion would be " persuasive " to a judge.

4. Unless the 9th Circuit heard the case and affirmed it, it will have

virtually no impact upon EMTALA's enforcement except in that specific court, and

we do not know what the same judge might do if the 250 yard rule were plead as

being a binding rule by the plaintiffs.

It appears that the plaintiff may have not had the best representation in

this case, since a reading of it and its history indicates some " false starts "

and mistakes.

Gene Gandy, JD, LP

>

> What ????????????What ????What ????What ????What ????What ????What ???

>

> Alan Lambert wrote: More info on the " 250 yard rule "

>

> From Frew's site:

>

> California Court Dodges 250-Yard Rule

>

> A federal court in California found a plaintiff who fell and

> was injured in the parking lot of a medical center had no

> claim under the Emergency Medical Treatment and Labor Act

> (EMTALA) against the hospital.

>

> In reaching the conclusion, there is no indication that

> the Court considered the CMS Regulation that added parking

> lots and similar locations within 250 yards of the hospital

> to the definition of having presented to the hospital for

> EMTALA purposes.

>

> The court explained its decision under the interpretation

> that EMTALA is a statute aimed at prohibiting patient

> dumping and once the plaintiff was taken to the medical

> center she received treatment and was not " dumped " in any

> way, the court said.

>

> The court further held that EMTALA contains no requirement

> that a medical center use its own personnel to transport

> a patient injured on its premises to the emergency

> department.

>

> Published accounts indicate Plaintiff Addiego was

> taken by her daughter to the California Pacific Medical

> Center (CPMC) for an appointment. As plaintiff exited her

> car in CPMC's parking garage, she fell and broke her hip.

>

> Although they were located about thirty yards from CPMC's

> emergency department, the parking attendant instead called

> the security department who refused plaintiff's request for

> immediate medical attention from the emergency department.

> Instead, security called 911. After plaintiff had been

> lying on the ground for nearly an hour, an ambulance came

> and transported plaintiff thirty yards to CPMC's emergency

> department.

>

> Plaintiff sued CPMC alleging the delay made her injuries

> worse and claiming premises liability and personal injury.

> Plaintiff also filed a separate action adding the City and

> County of San Francisco as a defendant and alleging that

> CPMC violated EMTALA by refusing to transport her to the

> emergency department, and instead requiring that the San

> Francisco Fire Department do so.

>

> The situation is strikingly similar to the incident at

> Ravenswood Hospital in Chicago where a hospital ED refused

> to assist a teenager who had been shot and lay just a short

> distance from the ED entrance. Chicago Fire EMS did not

> respond because it was an incident at a hospital and

> interpret ted the call as a transfer request. Chicago police,

> reportedly frustrated by the stand-off between the hospital

> and EMS, deviated from departmental rules and moved the

> child to the hospital ED just yards away. The child,

> however, died from loss of blood attributed to the delay

> in care.

>

> In response to this Chicago event, CMS added a definition in

> its Out-Patient Prospective Payment regulations defining the

> area of 250 yards around the hospital, including access

> areas and hospital parking areas, to be " presenting to the

> hospital " for EMTALA compliance rules. The rules also

> require the hospital to provide a response to the patient

> in addition to calling 9-1-1.

>

> While the decision is likely to influence litigation cases

> arising in the Northern District of California, it is

> unlikely to influence CMS enforcement of the 250 yard

> requirements of the OPPS regulation under EMTALA.

>

> Never-the-less, one wonders whether the court was provided

> information on the 250-yard rule and ignored it, or whether

> the attorneys' for the patient failed to present the rule

> that was specifically intended to prevent incidents like the

> one described. In either case, someone screwed up.

>

> The patient is fortunate that they fell in California, and

> not northern Michigan, or they might have frozen to death

> awaiting the delayed EMS response while hospital personnel

> ignored a seriously injured patient within view of the

> ED entrance.

>

> Addiego v. City and County of San Francisco, No. C 05-04819

> CRB (N.D. Cal. Feb. 17, 2006).

>

>