If you collapse at home, you call an ambulance.  Surprisingly, if you collapse meters from the hospital's front door, you call an ambulance there too.  At many hospitals, it's customary for nurses and other hospital employees not to aid bystanders who collapse outside the hospital's sliding doors.  Several publicized incidents and a public outcry have made hospitals rethink that approach.

On Dec. 2nd, a woman collapsed a hundred meters from the main entrance of the Chinook Regional Hospital in Lethbridge, Alberta.  A passerby ran into the hospital expecting to get medical assistance.  Instead, a receptionist called 911.

According to a man who witnessed the incident, the woman slumped to the curb of a hospital parking lot not far from the hospital entrance.  At the time, she was clutching a big bouquet of flowers and her purse. 

The witness attended the woman. When two other passersby arrived to render assistance, he went into the hospital looking for help.  First, he approached a hospital porter and then a receptionist.  The receptionist said she would summon help, and the man went back outside the hospital to check on the woman's condition, thinking hospital personnel would soon arrive with a stretcher. 

"I went into the hospital three times looking for help and assistance saying, 'We need to get the people from the emergency department to get a gurney out there and get her right now,' but they wouldn't do it. Instead they sent security guards to secure the area," witness Tony Stephan told the Lethbridge Herald.

It took roughly fifteen minutes for paramedics to arrive, put the woman on a stretcher and drive her to the emergency department - a short distance away on the hospital premises.  In the interim, no medical staff from the hospital rendered assistance.  Meanwhile, witnesses say the woman was turning blue.  A peace officer who attended the scene said the reason why she survived is that a witness knew how to do artificial respiration and started doing it before paramedics arrived.  The woman was admitted to the hospital's intensive care unit.

Vanessa Maclean, medical director for Alberta Health's South Zone, the health region that includes the hospital in Lethbridge, said there is no written policy stating that hospital employees are not supposed to haul patients who collapse outside the hospital to the ER.  However, Maclean said that in general, paramedics have been summoned to respond to patients who collapse outside the hospital.  

MacLean said officials are reviewing the incident and that they'll be happy to review their findings and how and whether they might do things differently in the future. 

Andrew Will, acting senior vice-president of CRH, told the Lethbridge Herald that the hospital is committed to improving the current practice.  He said immediate steps have been taken to ensure better communication and response, but the hospital plans an indepth look into the incident in order to implement a new policy for medical emergencies that happen outside of the building - one that spells out exactly who from the hospital does what in a similar situation.

I should point out that there's a big difference between patients who collapse inside the hospital and those who collapse out the hospital.  Hospitals feel a keener sense of responsibility for anyone who collapses inside the hospital.

If hospital personnel are to respond to emergencies outside the sliding doors, the policy has to be air tight.  First responders need to be designated; so too are the people tasked with bringing everything from a stretcher to a crash cart containing rescue equipment.  If a patient falls down a concrete stairwell, you better bring a board and a cervical spine collar in case you need to stabilize the spine.

See what I'm getting at?  It actually makes a lot of sense on some level to call paramedics.  ER personnel like me are good at triaging and treating critically ill patients once they get onto stretchers but not so good at is getting them onto stretchers safely.  Suppose the woman we've been talking about suffered an injury to her neck or another part of her spine.  You need to carry her while protecting the spine.  That's something paramedics do every day but something people like me might muck up because we do it once in a while. 

Then, there's the issue of who lifts the woman up onto the stretcher.  No hospital wants a nurse with a bad back doing a lift like that unless they want a major worker's compensation case on their hands.  Back injuries are among the biggest occupational hazards among nurses.  Once you're doing this, you probably need a dedicated team on standby.  That can be expensive to maintain.  And where do you draw the line?  Fifty meters from the ER?  One hundred?  Once you say one hundred meters, you're not going to say no to someone who collapses one hundred and ten meters from the hospital.

At the hospital where I work, we have a protocol spelling out who goes where to rescue patients who have collapsed inside the hospital.  For instance, if a patient suffers a cardiac arrest in the lobby of my hospital, an ER nurse is responsible for bringing the crash cart from our ER to the patient.  As the ER physician on duty, I run the arrest. 

I can remember answering the call to rescue would be patients who have collapsed in a taxi or other vehicle that has pulled up in the drive way beside the ER.  Someone grabs a wheelchair or a stretcher from inside the ER and we manage to bring them in.

It's clear to me that hospitals are prepared to take another look at how they handle this sort of situation. 

Doreen Wallace, an eighty-two year old woman, collapsed and broke her hip on Oct. 8 of this year as she left the Greater Niagara General Hospital in Ontario after visiting her dying husband.  At the time, staff believed only paramedics were allowed to bring patients like Wallace into the ER, and so they called 911 while she lay on the floor, face-down, in pain. A surgeon helped her into a wheelchair, but only after the ambulance finally arrived was Wallace taken to be treated.  Following the incident, the hospital conducted an investigation  and concluded that the quality of caring missed the mark and that some employees showed poor judgment.  In November, the hospital issued a statement spelling the steps it will take to make certain it's clear that when a patient collapses on the premises, staff should respond, not paramedics.

That these incidents are being well publicized makes it even more likely hospitals will be changing their approach in the future.

Just know that a policy like that will work fine until the day such a rescue is done poorly by hospital personnel.