Case Presentation: The logistical complexity of hospital-to-hospital transfer of care in the United States is well-documented. However, little is known about the processes involved in cross-border hospital transfer. This case illustrates the challenges and complexities of patient care across the U.S.-Mexico border.
Discussion: A 26-year-old Mexican male presented to the ED with hypovolemic shock via a “Cruz Roja” ambulance from a Mexican hospital. He had sustained a deep laceration to his right upper extremity after falling through a window and underwent aggressive volume resuscitation and unsuccessful surgical repair of the brachial artery from a hospital in Mexico. The patient’s family was advised to transfer the patient to a higher level of care across the border. After providing an upfront payment for a private ambulance he was transported under the care of paramedics to the nearest U.S. port of entry, where, emergency passage was requested. Once the ambulance crew’s immigration status was verified and a few brief questions regarding the patient’s medical condition were performed, the ambulance was granted access. The patient arrived at the ED without prior notification or sign-off. A Trauma Code was triggered to expedited emergent evaluation. Physical examination revealed a patient under sedation with a cool, pulseless right upper extremity. Arteriogram revealed an occluded brachial and proximal radial artery and ulnar opacification with no evidence of distal flow. Thrombectomy was performed on the brachial artery and a saphenous vein graft was performed with re-approximation of the median nerve. After 10-days of hospitalization complicated by compartment syndrome and multiple fasciotomies, the patient was discharged with instructions to follow-up with his PCP and the plastic surgery.
Conclusions: According to the Immigration and Nationality Act, a U.S. Customs and Border Patrol agent can authorize, at their discretion, “Humanitarian Parole” to any foreign national who seeks admission to the U.S. for urgent humanitarian reasons including circumstances that affect the person’s individual wellbeing. Hand-off communication was not part of the referral process and no advanced notice was received regarding the patient’s imminent arrival to the hospital for emergent care. Furthermore, Customs and Border Patrol agents were also unaware of the patient’s medical condition until the ambulance had arrived at the port of entry. The U.S.-Mexico border hospitals and health care providers face unique social, medical, and economical challenges resulting from poorly understood health care dynamics of patients transported across the border. This case illustrates the vital role of “safety-net” hospitals that are provided patients south of the border and showcases the urgent need to develop more fluid communication in the hand-off process for patient’s being transferred across the U.S-Mexico border.