 All right. Welcome. So thanks for coming a little bit early today for our ethics grand rounds. I think the discussion and the presentations today's are quite salient given some recent discussions that we've had as faculty and circumstances that that some of our faculty have faced in the care of transfer patients and patients outside our community who we provide tertiary care for. So this was kind of long in the making as far as a concept and it's really kind of come into fruition in recent weeks in a way that I think will be really hopefully engaging and interesting to everyone involved. So what we're going to be talking about the title is who is responsible the legal and moral challenges of accepting tertiary care and we have a wonderful panel who's going to kind of be leading the discussion of course Dr. J Jacobson who is well known to everyone here or most everyone here and is a professor immunitis in the division of infectious disease and medical ethics and has long been involved in our ethic grand round series. Catherine Hewd who is one of our cornea faculty who's going to be presenting a couple cases that she's intimately familiar with and then Jennifer Brennan Esquire I had to say that I really wanted to who is associate director of risk in the risk management department and she's going to be providing kind of a legal understanding and helping us navigate some of these questions from her perspective and expertise. And so without further ado I'm going to turn it over initially to Dr. Hewd who's going to present a couple cases and then we will go from there with discussion. Oh well let's talk about the agenda. First there'll be a presentation of two cases. We will provide a little time for an initial discussion just to kind of frame the ethical questions and some of the legal questions that might be a play and then we're going to turn it over to Jennifer Brennan Esquire for a more formal presentation on the legal framework and then we're going to have a time for a more complete discussion and that's why we also wanted to start earlier. So please be thinking of things that come to mind you know questions that are pertinent and important to you as we do these cases and as Dr. Jacobson frames the initial discussion. Thanks everyone for being here so early and for entertaining my 8 p.m. email. You might have gotten some supplementary materials. If you're in the room there's two cases kind of printed for you just kind of background context I think it's always really powerful to see you know kind of primary language that was used by the patient as well as also our transfer center system. So just really briefly for the first case this is a 50-year-old woman a 52-year-old woman with a known fungal keratitis so she was diagnosed and cared for by a community ophthalmologist at a large healthcare center but she presented to triage clinic in July of last year because her primary ophthalmologist said he was going out of town for two weeks and that she needed urgent management so she presented to triage she was seen by our cornea fellow this is actually not my patient but seen by our cornea service and admitted to inpatient medicine due to poor social support but notably the patient was actually out of network for the University of Utah. Just kind of the biggest highlight of this kind of patient-doctor relationship is that she was you know she had a lot of behavioral concerns there were also concerns of course of mental health excuse me and she was quite verbally aggressive to the cornea fellow who's taking care of her as well as our front desk and technician staff on several occasions her and her family were verbally aggressive in the waiting room and on multiple occasions mostly via my chart she would message the providers and the provider team multiple times a day sometimes multiple times an hour using sometimes profane or threatening language she also had poor adherence and no showed several visits however would either send kind of following you know following messages troublesome messages and ask for refills as well there were also several occasions where front desk staff I was the other cornea fellow but they would come to me the day before and be tearful and visibly upset saying you know this patient's on the schedule tomorrow I'm afraid of what she might do and then ultimately the original referring provider after they return from vacation we tried to plug them back into their system but they ultimately refused to reassume care of their patient she's had a pretty complex history she's still part of our service and we're following her closely but she developed a corneal ulcer and the other eye there were also concerns of you know self-harm from mucous fishing and referrals were attempted to be made each time that she no showed to other you know other clinics in within her network but ultimately she was able to obtain in network insurance with us and you can see kind of on the supplementary either electronically if you have it at home or just to print it out that she did send some messages these are the more more acceptable messages that I was able to kind of print and then also a lot of documentation on the other like I said our other cornea fellow did a great job in recruiting patient support services psychiatric help even a mobile crisis clinic to help her patient for those these are just some again some comments and then again kudos to my former co-fellow for handling this so well and being able to really attend to this patient if those of you have never seen a behavioral letter this is kind of what's issued so there's a documentation of a flag in the patient's epic and then also they get a mailed letter just stating you know what the incident was what our expectations are of patient respect but this was issued actually in February 2023 when they had already kind of displayed troublesome behavior for months in advance so I think beyond the discussion of this topic but something that we could have addressed earlier and then also this is something that my former co-fellow also wrote to the patient each time she no should have visit that you know she was told by her former the former referring doctor that she that he refused to re-assume care and that you know there were other there were other clinics in her network if she had to seek urgent care elsewhere so she wouldn't have to continue to pay out of pocket costs so fun and challenging case I'll just go on now to the next case again you have supplementary supplementary materials and this was brought up most recently at our faculty meeting in terms of just challenging transfer center cases so this was a 34 year old male from Las Vegas with an unclear history also poor historian but our faculty on call our Moran faculty on call was contacted on June 29th that there was a patient in the Las Vegas hospital emergency department and his exam was concerning for endophthalmitis however this was based off of a a description that the ed provider provided to their on-call ophthalmologist however the local on-call ophthalmologist refused to come in and actually examine the patient so our faculty on call said you know since you have an on-call ophthalmologist just have them come in and actually physically examine the patient then we can do an ophthalmology to ophthalmology discussion on whether this is actually an ophthalmitis and whether the patient needs to be transferred um unbeknownst to us and so this faculty member then never heard back from the outside facility but unbeknownst to us the CMOs and our wonderful transfer center team um actually were contacted back from this outside hospital and said actually yes our ophthalmologist has seen the patient we need to still transfer this patient for concern of endogenous and ophthalmitis um and you'll actually see on the transfer center record and for those who haven't seen a transfer center record this is if you go back to any patient um that is uh contacted through us for the transfer center they have this timeline of you know who reached out to who um how many times somebody called in what information um and they paraphrase the conversations and there's also recordings available but you can actually see on the second page that they reached out multiple times at least four times to this hospital asking for records um and the hospital refused or sorry failed to send records of the ophthalmology exam that they had said that they had completed um they also failed to um sign the transfer center agreement so then um when I was on faculty call on July 4th this was five or six days later the CMOs actually reached out to me directly to review records so they had said you know the University of Utah is at capacity and we're trying to figure out what the best placement of this patient is um it turns out that the patient was actually transferred to another Vegas outside hospital um for an ophthalmology exam and there was actually concern that the chief medical officers had voiced to me that both of the um hospitals were not being fully cooperative in disclosing information including uh comorbidities that the patient may need for inpatient needs such as an n-semi-sepsis cocaine use as well as a stroke and you can also see that in the transfer center documentation as well um the on-call ophthalmologist in Vegas at the second hospital who had seen him recommended transfer for endogenous and ophthalmitis but notably as I wrote in the in the papers um he did not dilate the patient and uh and just and he had recommended he said you know I'm not a retina specialist but this patient needs uh transferred to a academic center for a tap and inject with a retina in patient service and so my question which was an uncomfortable one is is it worth transferring this patient um you know who doesn't have a support system who may be homeless or have low social resources transferred to the University of Utah for maybe incomplete information maybe this is not you know the diagnosis and then um I might have been biased because we had recent cases of patients coming from Las Vegas and not being able to go back home um and you know are we gonna take a bed if the university is at capacity for this patient to come here when I know and we had reached out to local retina providers in Las Vegas that there are outpatient resources at the very least so I uh ultimately deny the transfer again um concerned about not having the patient with capability or support system in Utah in that the fact that it had been six days since the diagnosis was made um and um I had an uncomfortable conversation with Marcus our uvi just followed that he'll touch on later as well so anyway uh very uh complex and multifaceted cases for a discussion just to kind of launch um our cases today I'm gonna hand it over to Dr Jacobson here just in a quick second I'm just curious um lots to unpack in both of those uh cases and what are some just like initial things that feel most I don't know I'm pertinent or kind of um challenging to you from an ethical or or legal standpoint as you guys hear and review those two cases any quick comments yeah Dr Warner documentation I mean it was really extraordinary um and you know trying their very best especially I'm talking about the first case because the second case is sight unseen the first case is right there in your face literally sounds like um and uh incredible um compassion and documentation and every possible effort um given to get this patient the care that they clearly desperately needed both eye wise and mental health because they were completely wrapped up in each in each other clearly you you were not going to be able to get the eye taken care of without the mental health issues being taken care of and just amazing documentation and compassion absolutely and also piggybacking on that commending uh Dr Hooper putting together this like really unique glimpse into all that's happening and all that's documented within epic and around us as we navigate these kind of challenges uh Dr Kirsten quickly unclear what the hospital's obligation is the outside hospital's obligation to develop an appropriate referral network in community I mean historically everybody was on a hospital staff and you just had to take call and then I think ortho were the first people say no you know we want to get paid if we're going to take call so the hospitals reluctantly have started to pay a lot of different specialties but you know obviously there are multiple retinas providers in Las Vegas so if a local hospital chooses you know hey it's easier to just fly this stuff up to Utah and we don't have to pay you know somebody to take call down here is what are the legal implications and Randy has an answer and I think that that's a really important question that and one of the reasons why we invited Jennifer to be here to try to help understand some of these so sadly we're in a situation where uh it's increasingly hard to get people willing to truly answer call and it is true that there still is an obligation if you are at anyway in the hospital staff generally they get paid for it but they're supposed to be on call and not all systems are paying but the fact of the matter is is that more and more people are doing their surgeries in outpatient surgical facilities and not hospitals that people are not answering those calls or responding to their calls and I've talked to emergency room doctors and they find that to get somebody to really be willing to come in and take care of these problems is so hard it's just much easier just to call us that's true both from our local competition and it's definitely true at Las Vegas Las Vegas is a much bigger city than Salt Lake and what are they they're they're twice two and a half times our size they actually have a very high density of specialists scattered through there they have plenty of expertise to handle all of this they can't get those people in to take care of these patients this is a perfect example hospital too didn't dilate the patient took a look didn't want to take it you know not not a specialist you couldn't find a retinal person willing to come in and take care of this what's the option you know have them go here there was the economist wrote and there's Las Vegas is an unusual situation about you know the differences between Salt Lake and this is that London publication of those you don't know between Las Vegas and Salt Lake and then pointed out for the homeless issue which they thought we had a model program I mean we've got our difficulty but the model program that the the homeless policy in Las Vegas for a while was a one-way bus ticket to Salt Lake so we are facing a system in which but we can't continue to be the happy dumping ground we can't continue to be the ones to hang on hang on to these but once you get them it's the pottery barn problem you own it and and and then you're you know you're stuck in regards to that and these people who fall through the cracks so it's it's a it's a major problem and we'll I'm sure talk about the legal ramifications of what this means but in some way you know we need to be shaming places like Las Vegas and others that should be able more than able to take care of these problems but it's just much easier for them when they can't get people to just call us and dump a box absolutely and I think we face that that moral feeling of responsibility to just care for somebody who we can but then are we enabling a system that in time is worsening and worsening the problem that we're dealing with I'm going to turn it over to Dr. Jacobson to kind of now talk and help frame the ethical implications um and those are some really important and uh awesome comments to get the discussion going so thanks very much Eric and thank you as well um I actually agree I think the the sensitivity of the staff in responding to these and the complexity of these cases was actually pretty daunting so a couple quick things we don't all know each other really well so my field is infectious disease and it's almost a little bit odd that I would be with you often talking about medical ethics so just a couple of connections to see first of all it was interesting to me that the two cases that you've shown are actually on the list of the 10 most emergent conditions in ophthalmology as we had some pre presentation conversations about who would be most appropriate to help you with these the first one is I relate um so the idea of emergency is a very special factor in a case that creates its own sets of obligations it obviously creates a sense of urgency when you and I hear the word emergency we run in infectious disease I have a limited number also but it's interesting to me that a couple of them crossover with your specialty so especially interesting would be not just an injury to the cornea but a fungal infection and end ophthalmitis the same the other thing that's interesting about those two emergencies for me is that they often involve collaboration that is they immediately suggest that we need more than one person and frequently that's true for you too if it's an unusual infection in end ophthalmitis you want an ID colleague to help you if they start with me I urgently need you in terms of the technical skill of accessing the site so let's just keep thinking about that something that's urgent and requires collaboration and I think both of these cases do that the other thing I wanted to say quickly is how far these are outside the general scope of medical ethics we've had many many visits over the year the years and I just want to check with you many ethicists talk about four principles so especially people who have been in medical school more recently have heard those repeatedly can any of you name those four principles of medical ethics or even one of them yeah you're thinking so autonomy often the one that gets the most attention it's really at the top and let's just keep thinking about that it's patient autonomy which is so interesting about these cases both of these cases I would say are about risk and I understand risk right another thing that's important about my being here is in the face of an epidemic the whole medical community legal community and the public has to deal with the issue of risk so that's actually very personal right but infectious disease docs actually make a choice just like firemen do that they will enter a field which could present a lot of risk to them not all other docs have kind of mentally contracted in that way so this is a case about risk one could be about personal risk and danger in fact you shared that many of the residents express fear so fear of harm certainly fear of offense or abuse is an issue the other one is very much about economic risk to a whole group of people people on the outside and on the inside so these are cases about risk autonomy per se doesn't say much about risk and it overweights the idea of patience the way that you see autonomy here in part is the respect that was shown for a patient that was particularly challenging can you remember another one say again justice I'm going to hold that for the end which is where it normally is justice is usually listed as the fourth if you think Hippocratic oath and what you thought was in that you may have a clue there are two in between so I have autonomy a b that might help go ahead yes so they're first of all they're big words and they mean really simple things right beneficence is very relevant here it's about a sense of obligation that we have the first one would be obligation to respect patient autonomy the next one is the obligation to do the best that's actually the idea of the best for the patients or at a minimum do something that's good for the patient and that's often framed in patient terms do the best thing for the patient what's best for the patient so you notice for the first two not a lot of emphasis on the doctor or the physician right non-maleficence is kind of an echo back to the idea of do no harm it's really very similar but in a way they're getting the boundaries if beneficence is do a lot of good or the most good possible non-maleficence is do no harm a good way for you to think about that is do no net harm right when an orthopod amputates a limb because of gangrene back to my field he's doing harm people don't walk as well with one leg but they may be saving their lives correct so non-maleficence do no net harm again think about who the references or the frame it's do no net harm to the patient just as beneficence is for the patient so we're down to the third principle and we haven't yet really addressed the physician the last one is justice and justice is largely around treating patients equally that's where the justice is about many things but in medical justice when you think about and our lawyer is here you think where policy is it really is focused on equal treatment and it even applies categories some of the things that you can't do now i'm talking about what you can't do now what you must do what you can't do is discriminate based on can you help me what can you not do in the service of treating patients equally you can't refuse treatment because of what you can you can refuse treatment because of ability to pay isn't that fascinating it's a group of ophthalmologists where randy might be the one to say that first in many parts of the world that's construed as a very important part of justice that is they would see that as discrimination you're living in america and there are categories i bet you can name them if you think now take that one off the table what are the reasons you can get in trouble for refusing care oh there they are i work on hate crimes and they're actually the same categories national origin race ethnicity color gender gender preference etc but in america and in medical ethics pay is not at the top of the list i'm going to stop now because there is a list on which is the top it's called mtala so randy is actually right despite my quick reaction but it's very important that you think of the detail mtala and we'll hear more from the lawyer about policy is in a way the the effort of the united states of america to rectify an injustice i'll just say that again it's our effort to kind of put more in that last principle but it's for the country right but it was very it didn't come from docs i i will just tell you that mtala did not originate with physicians but it's very focused on emergencies and as you'll hear it's the place where it really lands is on institutions it lands on hospitals and i'll end with that it always and has been the case that physicians were connected to hospitals in an almost obligatory way if you were going to operate a tertiary quaternary hospital you had to have every specialty available so the assumption when mtala started and randy alluded to some of the new developments and exceptions was that you could control emergency care because it occurred in emergency rooms and they came under this rule as that relationship has split apart we actually have a big vacancy a vacuum in the idea of how you get justice for a patient who is excluded because of ability to pay so i'm going to stop there and see what we can hear from jennifer yeah that's just absolutely excellent quickly we're going to move forward to opening the playbook and discussing a legal framework i just wanted to give a credence to one of the comments from the chat which we don't have to discuss right now but just to put it out there since it was part of the initial discussion which was dr chai asking why can't we charge other states or healthcare systems to take care of these patients you know it's so in a way that we could send them back when stable and while there may be many specialists in vegas we might do a better job here so i think that the conversation there that has happened both with the audience and then with dr jaykinson has really really set things up well and i'd like to introduce jennifer brennan is uh is there a title side there we go jennifer brennan who is associate director in risk management to discuss the legal framework thanks you want to hear this i'm good here thanks for inviting me to be here this morning i'm one of the we have three lawyers now in risk in our group if you haven't interacted with us uh we hope to be a resource to all of you and when you have these kinds of situations come up where where policy and legal implications are in play or patient consent um anything like that we're happy to try to advise we get um we review all of the rls if you've heard of that system hopefully you have um every rl that's entered is reviewed by our office um we are available 24 7 if you're having middle of the night emergency we're happy to take the call from you you can page us you can call us um just ask the hospital operator to connect to you to us and someone is always available to try to help with whatever situation you have you're facing and these two cases are really interesting because we see disruptive patients we get those calls we have a weekly meeting now because there are so many more than there ever have been of patients and family members um parents just just making our providers lives tough and there are resources within the organization that were were um used in the first case i mean that was just like picture perfect as dr warner pointed out we couldn't have asked for a better um handling of that situation the providers did exactly what risk and customer service would have advised and the documentation was exceptional i mean it was it was excellent so um i mean these are all pretty obvious um points but certainly when you're faced with disruptive patients upset patients and families it can make taking care of that patient really hard and it can damage the relationship right and so we do have a process within the organization to terminate patients you can you can terminate them sometimes you think you can't but but you can if if they're if they've destroyed the therapeutic relationship um and so the key is to document properly right you know sometimes we get a call from a provider who says oh this patient has been driving me crazy and is being abusive in every appointment and then we pull up all the notes and they say patient is a 52-year-old pleasant gentleman from such and such and such you know you know when if that's what the notes say and there isn't documentation of the disruptive behavior then it it's hard then you the legal question is the issue is abandonment right i mean we don't want to be accused of abandoning patients that can have its own implications um and so we do have to follow a process to terminate these kinds of patients and so in this case there was the letter that said from the provider looped in customer service which is appropriate um they help with letters and we advise on those letters as well we we collaborate with customer service every day the letter said hey you know at your appointment you you yelled at staff you use profane language you know you can't do that okay and if you do it again then there are going to be consequences and that's important to have that documentation in the record because you're just setting up the patient you know for consequences same thing with no shows i love the letter that said hey we've been trying to get in touch with you you know you haven't come to your appointments you need to come and and be seen you have these in these issues that need to be monitored and addressed that's awesome we love we love seeing that's exactly what we would recommend and then you know at a certain point if the patient is no longer cooperative or showing or participating in their care you can't care more about their health than they do right and we can terminate them we can send them a letter saying we're not going to see you anymore we're happy to fill your medications for 30 days and good luck and and that is possible so but it is a process my chart of use we see that on a regular basis we probably get a couple calls a week about that patients overusing my chart using my chart um inappropriately saying inappropriate things we can restrict that access we can turn we can turn off my chart for patients who are not using it appropriately um so you don't have to to put up with it um but there so there are ways to try to control that environment um so that you're not feeling overwhelmed and and inundated with inappropriate messages um and we have the BERT team I don't know if any of you have had to activate that but there's a behavioral emergency response team within the hospital that's kind of a combination of customer service and security personnel who can come if if if you have a patient that's you know we have had patients break the hand sanitizers off the wall walking down the hallway you know we've had we've had all kinds of of screaming abuse we've had patients say I'm gonna go home and get my gun and come back and take care of you you know I mean we've had these horrible horrible scenarios that put our our staff and providers at risk and psychological consequences of those interactions are real and so we do have a behavioral intervention team that can come you can call them and they will they will show up and and help support the staff so that you don't feel unsafe or or in danger um and we've I mean we've had to put out bolo's you know for patients that have threatened us risk management now has bulletproof glass because we've had people threaten us you know that they're gonna come and and you know take care of us and so it's it's a really unfortunate and a scary environment sometimes for providers and staff in the medical field and I think it's something that has gotten worse we certainly are getting more calls and more threats and it it it just breaks my heart that you know these are you all are the ones that are trying to help people that's why you go into medical care and and you have to to deal with these kinds of situations it's wrong yeah yep um you mean that the patient or the family member actually hurt someone um I don't think so I mean I do think you know certainly anyone can accuse anyone of anything that's what we see every day in risk management um I don't see a risk to the providers I do think that best practice would be to try to address the behavior you know not ignore the behavior however whatever that looks like you know taking it up the chain of command taking it to to security or customer service if there's a fear of harm if the person is making specific threats then you've got you know the terrace off obligation of you know duty to warn whoever that the target is of these specific threats like if the patient says I'm gonna go home and kill my wife you know then maybe you make a call to the police you know certainly can't the security at a minimum hospital security at a minimum for guidance on what to do with that situation but you don't yes I think you do if you if you become aware of a specific threat physical threat then I think there is an obligation a duty yes do report I think over reporting is the way to go rather than under reporting yeah yep absolutely yep yeah sure and then you know Imtala that was the that's where we're heading sorry to take that diversion back to the disruptive patient but that was the the order of the cases so yeah Imtala is is its own kind of world um it was enacted I can't remember when a long time how many years 86 yeah wow okay so the idea was back then um there was a problem of the patient dumping and you know the problem hasn't gone away right so this law was enacted to try to deal with the problem of hospitals dumping patients on each other you know the patient shows up in the ER that nobody wants them so they just dump them at another hospital and so Imtala was enacted to try to address this problem so that patients who are presenting to the emergency department can get the care that they need right and so it created an obligation on all hospitals that participate in Medicare and Medicaid to follow these certain rules and regulations about how to deal with people who present to the emergency department and so it's it it prescribes very specific steps and specific personnel that have the hospitals who participate in Medicare have to follow in an emergency department setting and so that's just you have to kind of put your head in this this applies to emergency departments so um patient shows up and and of course each step of the way has its own terms of art and definitions so if a patient presents to the emergency department well what does present mean is is it in the parking lot of the emergency department usually the answer is yes so you know that has been elaborated on by CMS in lengthy regulations so it's within 250 yards of the emergency department so you know all of these these specific rules have expands expanded regulations that define the rules so the patient presents with an emergency medical condition well what's an emergency medical condition right we talked about the the different eye emergencies and infectious disease emergencies and so it has to be an emergency medical condition okay and then then the hospital at which the patient is presenting so the vagus hospital has to do a medical screening exam what's a medical screening exam lots of rules about that by qualified medical personnel what's you know all these things are defined within the law and then the patient has to be stabilized and then if they need to be transferred somewhere else then the receiving hospital the transferring hospital has to arrange the transfer and so that's the this is the framework that we're talking about um that applies to the some of the some of these situations right if the Las Vegas hospital admits the patient they're out of mtala then it's mtala doesn't apply anymore and so the reason um mtala was enacted was because of the the financial justice question that was raised earlier we didn't um the us congress didn't want people to be turned away because they can't pay um and so you can't if a person presents to your emergency department you can't ask them about ability to pay you can't ask them what's their insurance you can't say hey you're not in network here do you really want to stick around in our emergency department that's an mtala violation and and the law is structured so that um hospitals have to narc on each other basically so we don't self report like we look into all of our potential into mtala violations internally our group looks at those and tries to figure out if there are process improvements that need to happen so that there isn't a confusion in the ed or whatever um but it's it's a i tell on you kind of uh our obligation is to tell on other hospitals our obligation isn't to say hey cms sorry we messed up and we didn't we turned this patient away that's not we don't do that we say hey cms las vegas dumped this patient on us and if and then cms the department through the department of health typically will investigate these violations and fines are high for mtala they're huge they're tens of thousands of dollars even hundreds of thousands of dollars and your participation within medicare can come under threat and so it's a big deal to have mtala violations because all of your reimbursements could be put at risk and so i'm thinking about listening to these examples like do we need to report las vegas to cms i mean you know and and so that's something to keep in mind if and that may be the way to control these to try to control these situations there are a couple things that i thought of so the receiving hospitals have obligations so a person calls a transfer center and says hey i've been a patient with the medical emergency i've done all of my steps um you need to take this patient while there are rules in mtala about the mtala about the receiving hospitals so i put a quote from some of the regulations so the anybody who has specialized capability so we have a burn center here right and so when people call us and say hey we've got a patient with burns we have obligations because we have the specialized service and so we have to take them if we have a specialized service and someone has an emergency and we get called we have to take the patient um if it's appropriate right and so if the patient is stable and has been admitted to the hospital that's not a transfer under mtala and we don't have to take up we don't have to take them um but we don't we also don't have to take them if we don't have capacity and that was the issue in the second case we didn't have capacity we are maxed out and we can say no even if in our hearts we know hey we are the guy we are the people who can do the best for this patient so you feel that that impulse like oh we have to make this work because we're we're better than everybody else in las vegas we have the specialized skills we have the equipment we have the advanced knowledge it's it's it's our duty to to do right by this patient's the the beneficence right we have to do the best thing for this patient but if we can't fit them in we don't have to and so we can we can say no and we probably should say no because at the end of the day if we're trying to squeeze someone in maybe we aren't doing the best for that patient if it's going to be too much for us to handle you know um and then the chronic issues we've had chronic issues with surgery where you know we've got some local providers who maybe are a little bit out of their depth and end up post days or weeks post surgery getting presenting to us with their post op complications you know there's one particular surgeon in town that that our general surgeons end up mopping up after and and that came to a head at one point when there were you know transfer after transfer of of these these really sick post op patients from this one provider in town where the surgeons the general surgeons we got to do something and so they worked with tom miller to make a formal complaint to the to double about the surgeon you know and so that can happen so there are ways of trying to control if you've got issues chronic issues um the cmo's can help with that and we can advise as well in office of general counsel when it gets to that hopefully that's helpful and jennifer i was going to say thank you for saying that about you know the hospital being at capacity i think marcus and i we were saying you know there wasn't any maybe ethical vial or legal violation but we've had a lot of moral injury just denying these patients and the cmo's actually i didn't talk to the transfer center when i was on faculty call the week after they had contacted somebody else before me but it doesn't feel comfortable and i think the cmo's emphasized you know um a lot of las vegas or a lot of las vegas facilities not just ophthalmology have been kind of dumping patients on on our um on our services and we can't get we can't transport the patients back they get stuck here sometimes for life um and also you know they emphasize to me when you know we we can't keep taking care of other patients when we can't even take care of our own communities and that's kind of what i took away from that case but it was definitely you know kept me up at night for several weeks right you're worrying about this patient that you know has this problem that that we could help the ultimate injury thank you jennifer i think that was um actually really informative and enlightening um to try and to understand what are legal implications surrounding this and what i kind of get is there's very kind of well-defined parameters to where you're in uh operating within legal obligation but it's quite easy in cases especially with an ophthalmology to fall outside that very clearly defined parameters and then we start to operate more in the realm of ethics and trying to be a good steward within the medical community that means considering financial risks to institution to the patient um and then also considering this idea that has uh grown in conversation particularly through covid and that's moral injury to physicians and providers and and healthcare staff nurses everyone which to me seems like in these cases can go two ways one the moral injury or the ethical quandary you face when you deny somebody who you do feel like you or your institution might provide the best care but then also the moral injury that can happen when you accept someone and you find yourself caring for them in a much much less ideal environment in creating complexities and creating problems within their life that you know we're set up by the system and you're just in charge of kind of like picking up the pieces right and so there is no clear answer in the in these scenarios and then also caring for the patient who is abusive and threatening but yet still really needs high level medical care and if you discharge them or fire them where do they go because they've kind of been de facto fired from a community provider right um maybe didn't do it formally but you know did it in in in action um and so I really want to get to some more discussion uh amongst the audience and with uh with with the panel here um but quickly I wanted to offer the opportunity for either Mubarak and or Marcus to discuss kind of what it feels like or what their perspective um as the person or people who are often really charged with the care and like the day to day you know these these are our ground you know soldiers right these are frontline warriors who are actually dealing with this on call and then in follow-up if they do get transferred and what it feels like and how it um has changed their perspective on some of these issues absolutely thank you so in regards to kind of the resident perspective and as Eric mentioned um you know oftentimes residents are the first folks that see these ocular emergencies on call and certainly I think over like the past couple of years we've realized in terms of kind of the staffing issues and kind of the quality of care that we're able to provide in terms of just the number of patients we're able to see here at the Moran so you kind of have the systems issues there but kind of on a personal level with direct patient care amongst residents um you know you have a lot of these transfers you have you know a large number of patients that you have to see within a certain time period um and at least for me you know some of the most distressing moments have been um you know just being overwhelmed with the number of patients you do see uh particularly with you know these transfers and patients not able to receive care elsewhere and in many ways uh kind of being at the whim of providers to kind of tell you information not seeing patients uh within a certain time frame where you yourself feel like you know I hope you know this person does not have you know a site printing um uh issue at hand that I you know did not see you know in time you know you have an orbital fracture or a concern for endothemitis you know a provider's not able to tell you what the pressure was because they don't have the capability to you know perform a pressure in the ed at primary to children's um those are the moments where you know you do feel like you know um as that volume increases the care that you're able to provide as a frontline provider might not be uh you know to the quality that you you would like um and then in terms of um the other situation we had the other case where you do have a difficult patient um you know oftentimes residents do see these patients you know 2 a.m. 3 a.m. with no one around I think we've put in um systems to help with that in regards to you know the security being available when patients do present to the Moran but it is still difficult to to see a patients you know who it might be verbally abusive might you know be threatening and those thoughts do come up in terms of kind of your responsibility for that patient and even though we're not you know the ultimate um uh responsible provider you do you have you know a fellow or an attending that's overseeing the care you provide you are with that patient at that moment and even as a trainee there's still a power dynamic you know between the patient and yourself and um at least you know the thought I always had was you know regardless of um you know the the uh outward showing of you know whatever situation that the patients you know having in that moment where they might be abusive or um not you know happy with the care that you provide you you still have an element of control over their life because you know they might have a medical issue or an I issue and you know you are tasked within this health system of you know providing that care so in many ways you know at least for me I feel like in terms of like repairing a patient provider relationships oftentimes it falls on the person with the greater power dynamic to help try to fix that issue and I think that previous fellow who was involved in the case with the cornea also just did a fantastic job in terms of you know continuing to reach out to the patient even despite um you know the slights that they were getting in and you know the stressing comments and things that that patient was doing to them so those are just initial thoughts I'm sure other residents will have you know their perspective and I'll let Marcus also tell him perspective as well um yeah so I think I'd probably just echo a lot of the points that have already been made at least with regards to that second case um I had my kind of first experiences with something like faculty call last year with getting these transfer center calls and with actually several situations of kind of on the same spectrum of that end up feeling somewhat complex and kind of elicited feelings of of guilt even just with how to kind of go about taking you know taking care of these situations so I think that comes from a place of um as you had mentioned just I think uh at a baseline you just want to take the best care of of of a patient and of someone who's suffering as you can and knowing that we're at a you know a tertiary academic center where we have all of the resources available and all of the people available to take care of a patient I think it feels the the easiest and the most natural to just you know accept whoever you can to to take care of them in the way that that you know how but then there's these various layers kind of with these situations that make it feel a little bit more complicated and I think it's helpful to kind of think about or kind of these questions that arise of you know what is the responsibility of the transferring center to try to be seeking out more local resources in a place where we know that there's there at least presumably should be numerous subspecialists that that have the ability to take care of a particular problem as opposed to transferring a patient who already has limited social support and which is less ideal to be transferring them to another state and similarly if you know that the hospital is already at capacity and again how much should we be pressing you know the transferring center to be seeking out more local resources as opposed to you know waiting for a a bed or for you know a transfer that might take even more time for an issue that's already time sensitive and has already waited several days and then I think there's the question that I have that also comes up as Catherine mentioned of just how much should we be pressing to get as accurate and complete of information and documentation from the transferring center as possible to be able to make an informed decision for what ultimately ends up being a you know a costly and time intensive transfer you know and how much of that should be coming from an ophthalmologist or from from to what degree should we be seeking out that information before ultimately accepting a transfer and I think all of these questions we kind of touched on and I think at the end of the day again it can elicit feelings of of this kind of guilt and moral injury because you just ultimately you want to just take care of someone who it feels like might be falling through the cracks somewhere else and the easiest thing that at least I know how to do is just to take care of a patient that's in front of me and so and so I appreciate kind of hearing these different perspectives yeah I think that that's a really good point is it's really hard to push back because we feel antagonistic like we're like not wanting to care for the patient but by just being someone who says yes yes yes or institution we start to enable the problem like Dr. Olson kind of alluded to earlier and so now I'd like to kind of open things up first to make sure we have time for audience members to either share their thoughts or ask questions to our panelists and then just kind of let things also evolve naturally with Dr. Jacobson kind of leading the discussion but if anybody has any thoughts or questions that they'd like to to contribute now I invite them these are just questions that some of us came up with as just you know a guiding framework but like Eric said just open it up to any questions that you might have I've kind of I've kind of a logistical question because I know and you mentioned the importance kind of in that situation of the disruptive or troublesome patient we talked about the importance of documentation and you know you mentioned like when people address or approach risk management about possibly terminating a patient then you're saying hey there's no documentation of these behaviors anywhere I know as a provider in my documentation of visits and in notes I'm always trying really hard to stay as objective in my documentation as I can mostly again with the idea of justice in mind for this patient of not wanting future providers who are seeing them especially in our resident context where they might not be seeing the same person every time of being biased and that subsequent encounter or of not believing the patient or not taking them seriously just because of you know maybe their behaviors or other things going on and so I'm often hesitant to put those things in my documentation because I don't want it to affect the care that they're getting or the clinical decision making but at the same time you're emphasizing the importance of documenting these things that are happening so that if this does come up so I guess I'm trying to figure out both the logistical question of where is the best place to document these behaviors so that we can rely on that without having that confound or affect the objective medical care that they are getting question absolutely I think but I think you had the answer already in the question right the being objective right you can say if let's say the patient was having a bad day and yelled at you during the visit you could put in your note unfortunately the patient raised his voice at me during this visit I mean as long as it's it's describing facts and you're not saying the patient was disruptive that's kind of that's not very helpful nobody knows what that means patient was obnoxious patient you know aggressive I mean these are all subject to interpretation but if you put in your note fact you know the patient used profanity when speaking with me you know and you can say you can even say unfortunately you can you can kind of couch it so that maybe it was a bad day for the patient and the next provider who reads that can say oh well you know maybe that patient was having a bad day you don't have to say that in your note but I think if you keep it sort of whatever sort of is the minimum amount necessary to document what happened I think that would be enough right if it becomes a pattern because a one-off is a can be a one-off everybody has a bad day you know I I had a bad day at the end of the day yesterday with a colleague that I'm gonna have to go circle back with today to rectify right you know so it it but I do think it is important to put it in there and and sometimes a patient will come in our family member will come in and there's never there's no priors if you will but the behavior that that they exhibit is so bad that it's like that's it we're done you know you don't have to put up with I don't want anybody to the takeaway here to be that you have to put up with behavior for a certain amount of time before we can actually have enough whatever that is to terminate someone sometimes just out of the gate it's it's you're done I think you come in and you physically threaten someone you come in and you exhibit violent behavior you're done okay so let I don't want anybody to think that you have to be a victim for a certain amount of time for it to be enough to terminate so I hope I don't want to give that misimpression yeah just a couple important background things that are different for us and for other countries so for example Randy's illusion earlier to the Medicaid issue that there's a whole state that's acting on paraphrase what he said irresponsibly not stepping up to their obligations that again is very unusual that is some of this the the concerns that we have here are really about a system that is not feeling a sense of responsibility or obligation that's a really important thing to think about I would just say the comment that Mubarak made about power is really important you've been using words I heard guilt and I heard moral injury nurses who are arranged clearly in a hierarchical system of power use a term called moral distress and I think it fits very well especially we're hearing it from the residents but it can come from a chairman as well it's where you feel a sense of responsibility but you do not have authority it's the idea of obligation but no control you can feel it as a junior individual in the staff where you don't have the skill you feel like you the 2am comment is really really a good one that's where you sometimes see a problem you want to help but you don't have the tools and we're set up to help you with that right with a phone call what you're talking about today in many ways our phone calls that don't come to a solution right you're calling back to Las Vegas and they're not responding we hope that for residents that when there's a supervisor that you call that they respond but how awful and frightening it is if you don't have the skill you don't have the power and you call for help and there's no help at the end of the line so very very important to think about and we're essentially at the system's level now where that's what's breaking down the reason that you're feeling moral distress is that you can't make the system work for you the other thing I want to say is about an imbalance of power that's really hard to see as we talked about the principles of medical ethics you can appreciate most of them are actually designed to help the patient but the authority they're appealing to is you they're actually saying you need to respect autonomy you need to do the best and that's what the residents actually are really being clear about they feel this sense of obligation to do the best but they're literally a borrow word from urology they're impotent right and that's a terrible feeling of wanting to do the right thing and not being able to so a couple of things to think about we've also talked about resources I mentioned to you firefighters when there's a fire which is very risky they run toward it I mentioned infectious disease where there's an epidemic we go toward it in ophthalmology the risk here that we're talking about is not so much from the eye to you right or but it's the patient to you and I think when you have a threatening patient you really do want to think about resources there's a specialty that runs to those patients we haven't really talked about that you alluded to the BERT team behavioral was the word but think about the most abusive violent patient you can imagine that's a patient that gets referred to a psychiatrist in the ER that's the person that you call so one of the things that's interesting is that you actually in a sense have a place to go but it's very patient centered that is when you were thinking about risk and even the term risk management the risk that risk management is managing is your risk but as the residents tell us even these disruptive patients and many of them are mentally ill I would say at the extremes almost all of them so their risk is well but one of the risks that they're at is if we reject them or don't take care of them or protect ourselves we're okay but in the long run they're not okay I mean these patients that are not showing up for visits etc I mean they're going to lose an eye I mean that's just the way it's going to work for them so I'd really encourage you to try to think about it both ways in the area of error this is about root cause it's like what's really going on there's so much going on you're you may be in danger you may be absolutely right there's also a patient in danger and the tools that we have at the table are often your tools that is we have a risk management department working for us right and we have security that's there to protect us but you do want to think about that and you have to think about it at several levels one is again maybe a social worker maybe a psychiatrist there's a field called liaison psychiatry that we call on from the medicine side where you have somebody's medically ill but maybe they're also suicidal so we need a lot of help I think those would be good ideas in the long run but there are systems issues here that you don't want to overlook and again at thinking about mental health if that's only available for the people who can pay for it you really haven't solved that I want to just read to you a quote that affirms something that Randy said but it taught me something about how useful it can be for me to visit with ophthalmologists this is from i-net magazine so it's from your academy a dangerous trend has been percolating an emergency medicine over the past few decades across all specialties fewer and fewer physicians are willing to provide uncalled coverage of hospitals both for the ed and for inpatient consults as more community hospitals and apparently big city hospitals too face the difficulty obtaining specialty coverage the burden is falling on academic medical centers to care for a growing number of transferred patients so the first thing I want to do is put this in perspective for you you're not alone you actually share the risk here but isn't it interesting and in some ways it's because you're excellent you are an academic medical center you're committed to providing all of these services but in a world where risk and service is linked in some communities others are walking away from it so you know welcome to that world this is actually a choice but you of all people should really be concerned with changing the environment so that this risk can be more equally shared I wanted to go on what role does ophthalmology play in the growing crisis without a doubt the problem is occurring across many specialties said Charles Patavina at st. Joseph in Maine however in my own experience and I've heard this over and over ophthalmology coverage does seem to be the biggest problem in most places so I think you've landed on an enormous and significant problem and I'm going to just stop there a little bit but what I'd like to talk with you a little bit about is how to approach it acknowledging that the problem is much bigger than the individual clinician I think from the very beginning at this conference what we've heard are comments about how physicians in a sense are restrained careful they're they're actually doing two things and you should acknowledge that they're afraid both of patients in the first case finance in the second that is economic loss but they're really trying hard to act responsibly what I want to urge you to think about is you might not have thought about the levers to pull that is when you're calling the Burke team that may be protecting yourself but you want the best for the patient having the patient escorted into the parking lot out of the building is not helping them so we do want to think about that I'm going to pause there because there are some good ideas and you may have some other questions yeah I will say that you know obviously this is my co-fellow but we talked a lot about the first patient in the first case and in terms of getting behavioral help just knowing that you know fellows here are treated as attendings but we're still trainees so it was a really difficult you know case we actually reach out to Lisa Ord on a lot of these occasions just to get her thoughts and she's the one who directed us towards behavioral intervention teams that could even come to the patient's appointments and get her psychiatric help mobile crisis team we also consult psychiatry but you know it's difficult for my co-fellow who's a new trainee here to know about all those resources so I think that you know the Moran graduates are always a good resource but also just all of us should be more aware of who we can reach out to in these situations and like I said Lisa Ord in patient support services was a great resource to answer Erica's kind of question I also use a lot of quotes like in my documentation if you know you just want to just report the facts I would always quote patients and encourage my co-fellow to do so as well and then I think one thing that we had brought up before is yes you can you know it doesn't feel good to turn away a patient and maybe in the end that is not what's best for their care but in terms of net cost you know what is the cost to our staff taking care of these patients being fearful of coming in to work the next day when they see that patient's name on the schedule what is the cost to our trainees when they're put in this situation where they're getting a my chart message every hour several times an hour you know berating them I think that's something that when I think about this case we as a system could have addressed more readily any questions comments questions sorry not going back to the mtala thing it sounds as if the mtala business has sort of set up a bit of an adversarial relationship between the transferring and the transferee hospitals and then that's just kind of like a comment but looking at things from the maybe the national perspective or the statewide perspective people use the term system which is completely from my perspective at least not what it is because system implies something systematic and that is completely not the case I wonder what the obligation is for any given state to provide services for its citizens and just just just not anywhere in particular but I also wonder about say for instance academic medical center um Reno so they have a medical school there and one might think that now now that that none of that none of that they do have a medical school but why why Utah I mean it's I mean it's it's it's close they right but but you would think that with that that that would be their first place of transfer um and and is there an obligation does the state have any um fingers in the pie of um allocating responsibility for taking care of our own patients question so um each state runs its own Medicaid system and responsible for overall following these laws but each state has incredible autonomy in regards to what they can do inside that system so the only way these things can happen is if if for instance our governor sits with their governor and negotiates something which has happened in regards to water rights which is another area where the Nevada has often taken advantage of you know of some of these water issues along our border so it's it's a it's a difficult one in that in that uh and unless you can show that they're doing something inherently illegal that you take it through the court system that then you have to negotiate that and and so it's it's not easy and and I just want you know all the residents here back in my day a lot of the concern often was about ophthalmologists not being busy enough there's a big paper that came out in about 1990 that showed that there would be ophthalmologists on the street said we'll do cataract for a meal um and uh and and so it's now pretty obvious that as you look at where the situation and you look at where there's going to be shortage of providers um ophthalmology is is way up on that list in regards to shortage so uh you're all facing a future in which you're not going to need to worry about being busy your biggest issue you're going to be worrying about being too busy and part of that is is more and more people are kind of inundated is the lack of interest and willingness to take care of these kinds of issues I was told by an ER doctor at you know at at the big IMC I mean this is there this is a a major in you know it's even a somewhat larger tertiary care center here in salt lake right I mean this is their their Taj Mahal and there's no question that you know they are a tertiary center this ER doc said that while on call the odds of his getting an ophthalmologist on call to actually answer a plea is now at about 50 percent it's about 50 percent these are people on call I'm not talking about trying to get somebody else in and that's why increasingly they admit that they're referring it to us particularly sending it you know during to our triage center during the day but but others so it is a big problem and I think we need to in in our state society and others encourage people this is a societal issue we all have to take care of we all have a responsibility and there's a limit to how financially the university can take care of all of that need so it's something we're going to have to work up but there there are not simple legal solutions that and it brings to mind the the idea that the the ophthalmologists at other hospitals in the community throughout the country are the ophthalmologists that we as academic institutions train and so one of the the reasons in the energy behind this particular Grand Rounds is we need to be having that dialogue and conversation here so that the people who go out and become ophthalmologists throughout the country and whether a community or other hospital systems have that kind of ethical framework and maybe we can start shifting things because you're right it is it's only going to get busier and it's only going to become a bigger problem unless we do we kind of take accountability for ourselves as a as a profession which is a thing that has come up throughout these conversations to me is we are a profession right self-regulation calling out other hospitals self-regulation calling out ourselves that's part of being a professional both as a physician but also as an ophthalmologist within you know within medicine um any uh Brandon yeah just one quick question in regards uh like transparency of communication for these transfer center calls and kind of whose responsibility is it to document appropriately some of these issues for instance I remember when I was a resident patients would be transferred over because they couldn't reach the private on-call person for the academic or for the institution or whoever was on-call as a glaucoma doctor they didn't feel comfortable it's kind of these trends that we're seeing or just poor handoff communication they didn't stay in the patient they didn't check IOP kind of all these issues that are arise is that the resident's responsibility to document these things and these issues that are coming up or does the transfer center call kind of dictate that telephone call and where is that being documented and kind of whose responsibility is that to that Brandon because like you can tell again for the second case like they called back and said yes actually our ophthalmologist did see the patient and then when our transfer center recorded sorry requested records four times they they just didn't send records that this patient had been seen by an ophthalmologist and I think it's clear that they they weren't so um I don't think it's on the resident but I would say that our transfer center is amazing and you can call them back um and um say hey just letting you know that this wasn't you know you can they will document that for you and they actually have everything recorded and there have been at least when I'm on faculty call there are sometimes where you know they missed an open globe the provider missed something else or the diagnosis was incorrect I actually call them back through the transfer center and give them that feedback and say oh you know you had a suspicion for this but it was actually a full thickness cornea laceration that was side dub positive in an open globe instead of a you know corneal foreign body that you tried to dig after I've actually called them back through the transfer center and gave give them that feedback and then it is recorded I don't know if that's the best policy but I've been doing that and they usually are very appreciative that you called them I'll just echo I totally agree transfer center is really really good about documentation and so that's something that that can alleviate a little stress I do love the question about how do we document this and where just remember patients have access to their notes they can see them through my chart so if you haven't had a conversation with them in the moment and then in their chart they see patient was upset raised voice at staff that's not going to go well so if that's happened and how it typically happens you'll you'll see this later in your career they don't treat you poorly they treat staff poorly and there's a few people like Bob Hoffman others who are really good at this you have that conversation about acceptable behaviors and not you tell them this will also be in your note at the bottom just noting that we had this discussion that's going to set you up well and then finally you know such a great point about who we are and how we as a profession are creating this problem the the AUPO has had this discussion we've had this discussion among educators and it's this classic you know long long-term issue for us what's good for you as an individual your sleep your well-being your lifestyle is not what's good for the profession and that's where we we really one of the few levers we really have outside of awareness is selecting the right people for our profession and really the opportunity to move from just more USMLE score base to a more holistic review no pressure Rachel get the right people in so that they're going to be the people to take care of these patients in the future the right people you all know about behavior or operative conditioning you can take the right people and just ruin them by the environment that they work in and the stresses that they can't manage and they leave sometimes professionals choose to leave the covid epidemic has been very instructive for me to see what happens to very committed excellent nurses and physicians often because of repeated abuse which you've been talking about today so a couple of things to just look at here we talked a lot about language the word moral distress a very good one another very important phrase is unfunded mandate unfunded mandates when you think about entala which is a very well intended piece of federal legislation to right a wrong but the method that it chose is actually contributing to the problem that we're talking about today the hospitals really don't like entala it creates an obligation but there's no reimbursement look at the phenomenon in the country people who are unfunded and cannot be cared for even non-emergent conditions now seek out the emergency room under the premise that they are that there is an obligation there to provide care without funding and they're actually right the challenge for them is if they're not emergent that serious problem is literally ignored if they can be assessed in the er and judged to be non-emergent there's no advantage to them the er is wasted time the patient is wasted time and i really appreciate the comment about going to systems you're absolutely right i think a better way of saying that is going to society or going to a larger version of governance and caring than what we have we have either broken systems or non-systems so again a couple things to think about there what you can do um actually many of these problems are about money even when we're not addressing mental health it's often because you don't know who to call who will provide mental health for what is often an impaired and indigent patient the same thing is true about what you're describing in las vegas a lot of the motivation there is around not getting paid i mentioned that hospitals are afraid and a strategy for them is that they can keep the patient out of that er door they don't come under that jurisdictional level it's terrible it's all wrong from the professional standpoint so here are a couple things to think about i saw questions in the back one is what can the profession do um as our panelists know we talked early about maybe bringing somebody from department of professional licensing in some ways that could be a medical lever it's somewhat in your control i'm not suggesting easy but for example if you think it's professionally wrong for a doc to be intoxicated and operating you can make that stop i can tell you that you can make that stop if you think it's professionally wrong for doctors to evade or avoid their responsibility to see and assess or to take care of a patient who they already are in a relationship with but sending that patient away you could begin to think about that as a licensure issue i'm not aware of the state that's done that but i do want to say that that's in a way the most linear way a professional could think about making other professionals stand up the other one is at the societal level in other words if you could imagine a system where there was a literally a system a healthcare system that paid for leave the mandatory emergency visits but you provided funding for those a lot of these problems would go away so i those are just some strategies for you to think about um this idea of responding to nevada appeals to me i think randy is right that's the existing multi system problem governors talking to governors but that's not impossible that's something to think about the other one is at the licensing level and maybe you want to be talking with the licensing officials in nevada to see whether that behavior is in a sense an embarrassment to them that's their professional community and then finally be thinking about that when you go to the polls or when you hear about things that the us has been literally last in line for now for a long time which is some system even if it were emergency medical support we have children's medical acts we have special acts for people in certain circumstances but we've mandated emergency care and never funded it there are a lot of hands in the back yeah we're running out of time but i do dr kirsten and dr hoffman if you guys had something you'd like to add or