Air Trek Air Ambulance Educational Programs

• Patricia Duncan
  Sarasota Memorial Hospital
• Titus Gambrell
  Athens Regional Medical Center
• Nina Pascoe
  Tampa General Hospital

• Karen Harris Wise
  ACMA Florida Chapter Meeting Random Drawing Winner

Patricia Duncan

Sarasota Memorial Hospital

My most challenging patient was a 54 year old man from the Czech Republic who had been riding his bike while intoxicated and was hit by a car. I arrived on a Monday morning and learned during ICU rounds that this particular patient was on a ventilator and paralyzed from the waist down. I was fairly new to the ICU at that time, but despite being a rookie, I was able to recognize the catastrophic nature of this ill-timed bike ride.

The patient had been living in the US for many years and had some friends who were able to provide support and information while the patient was critically ill. The patient's mother and sister lived in the Czech Republic, their contact information was found and the physicians and team were able to communicate with his family. Due to the severity of the patient's injuries, it was apparent that he would require a long term recovery and possibly need a ventilator or long term care for years. I quickly began to inform team members that other than his current emergency hospitalization, the patient would not be eligible for any services or rehabilitation in the United States due to his citizenship status.

Aggressive attempts to wean the patient from the ventilator were unsuccessful and it was not long before the Pulmonologist working on the case requested a care conference with the care team, the patient's family by phone and administration to discuss the possibility of the patient's return to his country. At that time the patient was alert and following commands. He had received a tracheotomy, however was still on the ventilator and paralyzed from the waist down with no improvement. Despite the teams' awareness, I believe it was this meeting and the degree of involvement of the Pulmonologist that sparked the realization to all involved of the need for this patient to return home to his country.

I began with my favorite private detective, google.com and began to research the Czech Republic, it's culture, healthcare and hospitals. Eventually I called the Czech Embassy and was introduced to someone at a smaller Consulate office who became my lifeline. She asked, ÒWhat took you so long to call?Ó and then offered her time and assistance with the patient's transfer. The Consulate began to work on Visa issues as well as finding contact information and communication with hospitals. After much discussion it was found that the patient's sister was an Occupational Therapist in Prague and was able to investigate hospitals in that area and their ability to accept the patient. I began to find that using email, being very careful not to expose the patient's name or protected health information, was the most efficient way to communicate effectively with multiple parties and countries.

The cost of transportation to the Czech Republic was something that the patient and his family were unable to afford. The hospital administration was included in discussions early as his transfer included the need for authorization of the cost of transportation. Several air ambulance companies were contacted and estimates arrived which were forwarded to the Director of Case Management. She chose Air Trek's estimate which was expensive, however reasonable based on the distance, and as luck would have it, our hospital had an Indigent Miles program which became very useful in this case.

Believe it or not the last barrier I had to overcome was communication. I was becoming frustrated with the hospital and consulate while waiting for confirmation of acceptance and bed assignment. Our usual process for a hospital transfer involves; a physician accepts the patient, the hospital accepts a patient and tells you when a bed is available. After several conversations and some frustration waiting for a bed assignment, I began to understand that the Czech Republic was waiting for me to choose a day and time for transfer. Once we broke through this last communication barrier, I set the day and time, coordinated with the patient, his family, the hospital, the consulate, the air ambulance company, administration and the treatment team and the patient was safely transported back to his home.

Titus Gambrell

Athens Regional Medical Center

I took two steps onto the work shuttle bus and a person that I barely knew inquired, I guess you heard about your patient? I kindly replied no and didn't leave an opportunity to further discuss it. One thing I've learned as a case manager is that Mondays and Fridays can be full of challenges and surprises and this was a Monday. In fact it was a Monday that I was not eager to start, clinging to a wonderful weekend off. Nonetheless I was there to work- in a job that I absolutely love most of the time. I was a bit leery of the colleague giving me ownership of the patient and from history realized it may not be good. Sitting on the bus I began to go through a mental list of specific patients that I thought it might be. One unit that I cover is the nephrology unit with patients that I've seen multiple times over the years. I had a small list of the most challenging ones and figured it was one of them. I moseyed through the hospital and upon entering my department found multiple emails and calls from various people including my boss, a unit manager, charge nurse and primary nurse. All calls were of course about my patient.

As it turns out, this would not be a case typical for me. Besides the nephrology unit, I cover the surgical gynecology/urology unit and this was where the patient was. This patient was a medical overflow patient. She was young, in her mid-twenties, and very obese patient weighing nearly 1000 pounds. She had been unable to stand for several weeks. Her home health care staff and her spouse had finally convinced her she had to come to the hospital for treatment of fluid overload and stasis ulcers. The fire and ambulance staff of several units had removed a wall to bring her to the emergency department. Upon admission, the spouse decided he could no longer care for her at home.

I paused, but did not panic, there was no need to. I quickly sought out some internal support among my peers in nursing and social work case management, as well as the department managers, yet no one really had experience with such an obese patient. Having worked in post-acute care in the past, I knew there was not much of chance of finding placement in Georgia, so, I immediately recognized the need to explore options with the patient to include out of state placement. I knew it would still be challenging especially with having only Medicaid coverage however that's when I saw the liquid in the cup- it was not half empty. The patient had a payer source! The patient also had a willingness to consider all options. However, she had watched several shows about bariatric rehabilitation and she really thought we would find a resort type of placement for her that would take care of everything- start to finish. The Social Worker that I am paired with is such a dynamic case manager and began to work on that issue while I began to solicit some placement suggestions outside of our medical center.

Besides reaching out to some of our state healthcare associations, I also posted a message onto the ACMA learning links. I can't tell you the comfort in seeing how quickly responses started coming in. Many of them were not the right solution to this case; however, I greatly appreciated each and every one. Some were for support and those were welcomed, as encouragement was needed. One of the earliest responses ended up being the charm. It was for a facility in Ohio. The Social Worker was working her magic with breaking down barriers the patient was suddenly putting up about going out of state, or going anywhere for that matter. Being young, we were able to solicit the patients help with our search via use of her laptop. She also checked out the facility that we had found thanks to my learning links friends!

From the beginning, this case wasn't just a placement challenge. There was considerable care coordination that had to be planned and orchestrated for basic activities of daily living. Resources of manpower had to be planned around the clock as the nursing and therapy departments were not able to totally absorb the simple tasks of bed mobility and transfers in/out of bed. To facilitate and be a part of the coming together of multiple departments was awesome. The assistant unit manager was phenomenal. It was like a true joint effort with every angle of this patient's care needs being addressed with compassion, dignity and timeliness. The hospitalists and consulting physicians were so supportive and provided medical management while we managed resources.

Transportation was a challenge as well. We obtained quotes for hospital administration to consider, as the medical center was paying for the transportation. Some companies could not accommodate the patient for either weight, stretcher width or other reasons. To top it all off, there was a significant winter weather storm that crept into the scenario just the day before transfer but it all worked out!

In just over a week, our patient left in the early morning hours via a non-emergent medical transportation unit, on a 700+ mile journey. We pre-planned for her pain management en route, which was of special consideration with crossing multiple State lines. Again, an interdisciplinary approach yielded positive end-results. Two post-discharge contacts were made with the patient and all was well. Within a couple of months, we had a very similar situation. It is amazing how once a medical center's case management team walks through a situation, the next time can seem like old hat. We all learned so much, from our patient.

Nina Pascoe

Tampa General Hospital

In my career as a case manager, I have had many interesting and challenging patients and requests. Some have been memorable in their outrageousness; like the consult to arrange for the patient’s plants at home to be watered, or to find a caregiver for another patient’s cat while she was in the hospital. Once a family requested that their horse be allowed to visit the hospitalized patient. It can be difficult to find the best solutions for the patients and their families while balancing the fiscal side.

My most challenging case occurred at a different, much smaller, hospital than I currently am employed. The patient was known as the town drunk. She was a small, thin, likable woman with a seizure disorder. When she drank too heavily she would have a seizure and come to the emergency room, and from time to time need to be admitted. One day the ambulance brought her to the ER and reported that her husband stated that she had had a seizure and was taking a long time to wake up. She was somewhat lethargic and had been drinking so she was admitted. Less than 24 hours later she suffered respiratory arrest and required intubation and ventilation. She had no spontaneous movement and her doctor suspected that she may have had a stroke. A few days later when she was deemed stable enough to get a CT scan to verify the stroke; but with horror they realized she had a burst fracture of C1 and C2. These type fractures are usually seen in high impact trauma like a motorcycle accident and usually kill the patient.

The medical team and staff realized that she was now a quadriplegic. Arrangements were made for a neurosurgeon to have courtesy privileges to perform her surgery. The neurosurgeon suggested that the source of injury may have been from domestic violence.

The problems that I faced as her case manager were: she was on Medicaid, and was trached, vented and a quadriplegic. There were three skilled nursing facilities in the town and none of them were able to take a patient with that high of acuity. To top it off this was now a potential crime victim. In fact, the hospital had never had a patient like this either. In retrospect, if she had not been someone we all knew, her workup in the ER would have been more thorough, her injuries would have been identified and she would have been transferred directly from the ER to another larger hospital.

I investigated the possibility of social security disability for her and she did not have enough work credits to qualify. She was not eligible for any crime victim funds because she was not able to verify that she had been a victim of a crime. In the process, of searching for solutions, I learned about the Florida Brain and Spinal Cord Injury Program. She could not get any funds from the Brain and Spinal Cord Injury Program because the fund was too low. I started the institutional care Medicaid application for her so she could live in some nursing home somewhere for the rest of her life.

Much to her good fortune (and mine) she was able to be weaned off of the vent and started to regain some function in her limbs. When that happened, I convinced the hospital’s physical therapists to not only work with her but to spend extra time with her when they could. They were hampered in their efforts because the hospital was so small they did not have the right kind of equipment. Nevertheless, they did eventually get her to stand and pivot.

I had been pursuing the three local skilled nursing facilities (I had not yet heard of ECIN) to get her accepted, but since she was only in her late 50’s, by their standards she was not old enough for them. One day not too long after the patient achieved the goal of standing and pivoting, one of the admissions people from one of the skilled nursing facilities announced to me that the state had given them better rankings in rehab/therapy than the other two facilities. In the state of Florida, skilled therapy is not a covered service if you have institutional care Medicaid. Boldly, I suggested that they accept this patient and provide her therapy and prove that their therapy department was better than everyone else in town. In essence, they could claim that they got a quadriplegic walking again. I suggested this would be the ultimate marketing opportunity and would be worth the “donation” of the therapy.

The outcome: That skilled nursing facility did accept the patient and did get her independently walking again. The patient did admit to us that her husband had been the one to cause her injuries. Unfortunately, since she would not press charges and the police did not have enough evidence to charge him independent of her statements, he did “get away with it.” After the patient left the skilled nursing facility, she went to live with a grown daughter.

I now work at a much larger hospital where the “sickest of the sick” patients are the norm. Of course, I have had many very complex and challenging patients here, but have more resources available to assist me and my department. I will always remember this patient and how I was able to get everyone to pull together and do the right thing by her even though they were not making money doing it. For me, this case validated how important case managers can be in a patient’s life.

Karen Harris Wise

ACMA Florida Chapter Meeting Random Drawing Winner