Borders challenge emergency care

In the spring of 2012, a 4-year-old California boy was struck by a car while visiting relatives in Mexico. Believing he couldn't withstand the hourlong trip to the nearest border crossing, Mexican authorities handed the boy to San Diego Border Patrol agents, hoisting him into the United States over an 8-foot steel fence. The agents treated him for more than 40 minutes until Emergency Medical Services (EMS) arrived. The child survived, but the story illustrates the challenges of cross-border trauma care in an immigration-averse, post-Sept. 11 world.

Carol R. Immermann, R.N., trauma program manager at Saint Marys, one of Mayo Clinic's hospitals in Rochester, Minn., says similar problems exist on the Canadian border, despite a shared language and cordial relations.

For instance, EMS providers may not have passports, though they have been required for southern and northern border crossings since 2009. That means U.S. and Canadian ambulance services, each licensed in its own country, may sometimes have to perform the kind of patient handoff seen in the Mexican case.

Licensure is also an issue for EMS providers and medical directors because neither group is licensed in other countries. Laws governing the cross-border movement of drugs and medical devices are another obstacle, and customs regulations can interfere with air transport. Finally, because Canada's national health insurance is only valid within Canada, most Canadians prefer to be treated there, even if definitive care is closer in the U.S.

Agreements support collaboration

In spite of these challenges, patient care is never compromised, Immermann says, in part because international, regional and local statutes and paradiplomatic agreements encourage EMS agencies to work together to share resources and expertise in emergency situations.

One example is the International Emergency Management Assistance Compact, a mutual aid agreement between northeastern states and eastern Canadian provinces that enables one country to ask the other for assistance during catastrophic events.

Closer to home, fire departments in International Falls, Minn., and Fort Frances, Ontario, have established a mutual aid agreement for disaster preparedness.

Immermann points out that state borders cause far fewer problems than international ones do.

"EMS providers have to be licensed, but there is national licensure, so that isn't an issue," she explains. "And most states have established mutual aid agreements that set up specific rules to cover both small incidents and mass casualties."

Immermann says the main problem with interstate trauma care is the inability to share data across state borders. Once a Minnesota resident is taken to Iowa or North Dakota for treatment, that information is lost.

"There is a great need for a national registry that all states can access," she says. "Lack of data is a great stumbling block to effective cross-border care. The ability to conduct performance improvement activities depends on data which includes patient diagnosis and outcomes, and this is usually lost when patients cross state lines."