Why “Stable” Isn’t the Finish Line in Emergency Care

Written By: Asbel Montes, Co-Founder & Managing Partner, SGS & Dr. Nicholas Cozzi, EMS Medical Director and Assistant Professor of Emergency Medicine at Rush University Medical Center in Chicago, Illinois

The last piece in this series asked who gets to decide what counts as an emergency. We looked at three systems, Medicare's medical necessity and reasonableness test, the GAPB Advisory Committee's prudent person standard, and EMTALA, and how each answers that question differently.

That piece was about definitions. This one is about what happens after the 911 call. I asked Dr. Nicholas Cozzi, an emergency physician and EMS Medical Director, to look at the issue from the other side of that 911 call, the side no policy manual can fully capture.

Here's Dr. Cozzi.

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As an emergency physician and EMS Medical Director, I've stood at more bedsides than I can count where a patient looked, for the moment, okay. Vitals holding. Pain controlled. The crisis that brought them in has been addressed as far as our walls allow. And that's exactly the moment where the real decision begins: does this patient need a higher level of care, and if so, how fast do they need to get there?

Too often, "stabilized" gets confused with "safe." They are not the same thing.Stabilization means I've bought time as an emergency physician. It doesn't mean I've solved the problem. A patient with a bleed our CT can see but our surgeons can't fix, a stroke outside the window for what we can offer, a child who needs a pediatric subspecialist we simply don't have on staff - these patients are not cured by the fact that their blood pressure looks better than it did an hour ago. They are patients whose clock is still running, just more quietly.

A transfer isn't a courtesy consult. It's the next step in that patient's care,and every hour it waits is an hour where the underlying problem keeps moving while we stand still. The window for a life-saving intervention doesn't pause because it's dinnertime, or because the transferring hospital wants to finish a workup that the receiving facility could complete just as well, and faster. The emergency doesn’t pause because of paperwork delays, lack of staffing, or convenience.

Nowhere does this hit harder than in rural America. I've worked with EMS crews and rural EDs who move heaven and earth for their patients, often with a fraction of the resources of an urban academic center. When a rural hospital calls for a transfer, they're not being cautious for the sake of it — they've already recognized that this patient needs something they can't provide.Every delay from that point forward isn't neutral. It's borrowed time, spent by a system, not chosen by the patient.

That's the part we need to sit with: the patient didn't choose their zip code, and they shouldn't be sentenced by it. A person having a stroke in a small town two hours from the nearest stroke center deserves the same urgency as someone having that stroke three blocks from a comprehensive stroke unit.The distance is a logistics problem. It should never become a clinical outcome.

As physicians and EMS leaders, our job isn't just to stabilize and hand off paperwork. It's to keep asking, at every step, "what does this patient need next, and how timely and safe can we get it to them?" A transfer ordered promptly, coordinated aggressively, and executed without delay is still part of that patient's emergency care, not an afterthought once the emergency has passed.

Immediate stabilization is the beginning of the story, not the end of it.The patient in front of us deserves a system that treats the next step with the same urgency as the first one.

Read side by side, these two pieces describe the same gap from opposite ends. The last piece showed how Medicare, the GAPB Advisory Committee, and EMTALA can each reach a different answer about the same 911 call. Dr. Cozzi's piece shows what that gap costs once a patient is already moving, especially when distance and staffing are working against the clock instead of with it.

Neither piece is arguing that the people who wrote these rules got it wrong on purpose. Three systems built three separate tests, and none of them was built with the other two in the room.

That's where this series goes next. The first question was who gets to decide what counts as an emergency. The next question is what we do about the gap between how that decision gets made and how it gets paid for, which means looking at what could actually change it at the federal and state levels, while keeping the patient centered in the discussion of solutions.