A Minor, a Gunshot Wound, and Two Destinations

Treat first; consent runs alongside, not ahead.

• EMTALA: he has an emergency medical condition. The hospital must provide stabilizing treatment within its capability and transfer only for a higher level of care, with a written certification and an accepting facility. The absent surgeon and the 90-minute gap are the basis for transfer.
• Consent for a minor is ordinarily the parent's or legal guardian's, but emergency treatment proceeds under the emergency doctrine when delay risks serious harm. The grandmother at the bedside cannot consent; she can give history and be a support.
• Make and document a good-faith attempt to reach the mother by phone, record what she was told and when, and proceed. Document the emergency, the attempts, and the accepting physician.
• The patient's assent matters. A 16-year-old should be told what is happening and why. He is asking, and answering him is both ethical and clinically useful - an informed, calm teenager is easier to assess and easier to move.

The answer depends on how he responds to the first bolus - say so explicitly.

• The adult Level II, 25 minutes away, can open an abdomen. With a rigid abdomen and a heart rate of 122, the bleeding is likely hepatic or major vascular, and the operation - not the pediatric ICU bed - is what saves him.
• The pediatric center, 50 minutes away, offers pediatric surgery and pediatric critical care. That is a real advantage for a 16-year-old, but only if he has 50 minutes to spend.
• The discriminator: give a fluid bolus and watch. If the heart rate falls, the BP holds, and he stays mentating, the extra 25 minutes is a reasonable investment in definitive pediatric care. If he is a transient responder or a non-responder, or the abdomen is rigid and worsening, the nearest capable operating room wins.
• Who decides: the transferring physician, in discussion with the receiving facility, with your input on transport time and en route capability. Your job is accurate times and an honest statement of what you can and cannot do for him in the air.

Separate the two questions: consent to transfer, and choice of destination.

• If she refuses transfer altogether, that is not a decision the flight crew can resolve in the aircraft. Escalate to the attending, the house supervisor, and risk management, and follow facility policy. Do not delay a bleeding patient while adults debate.
• If she consents to transfer but prefers the closer hospital, the physician - not the flight crew - owns that conversation. Patch her through, give her the numbers, and let the physician explain the tradeoff.
• Both hospitals can operate, and the nearer one is 25 minutes away. If the mother, informed, prefers the nearer capable hospital, that is not an unreasonable request, and the emergency doctrine is not needed to override her. Where the closer facility genuinely cannot provide the needed care, the physician documents the discussion and the medical necessity, and the transfer proceeds to the indicated destination with the institution's process handling the disagreement afterwards.
• Document the call: time, participants, what was said, and the decision.