Highway Patrol Pays out $4.5M to Girl Paralyzed in Auto Accident
Posted by Patrick Lickiss on May 27, 2011 in Current Events, General, Legal | 0 comments
The California Highway Patrol has agreed to pay out $4.5 million to the family of a girl, now six years old, who was paralyzed following a motor vehicle accident resulting from a police pursuit. The girl was twenty months old on April 7th, 2006 when the car she was in was struck by a pickup truck driven by a man fleeing from police. A Highway Patrol officer removed the girl from the vehicle and her attorney states that the officer did not provide stabilization to the girl’s spine causing her injuries to become more severe according to the Bakersfield Californian.
WHAT CONSTITUTES NEGLIGENCE?
Based on the tone of the article, the claim in this case appears to have been negligence on the part of the CHP officer. In order to prove negligence, four elements must be present: duty, breach of duty, causation and damages.
Duty, also called “duty to act” applies to paid responders and volunteers when in the capacity of their position. I, for instance, am a volunteer flight medic. When at the hangar or on the aircraft, I have a duty to act. When driving to and from the hangar, I don’t. In this case, the question is whether the officer had a duty to render medical care. While reading through the CHP website, it appears that officers going through the academy now, are being trained to the Emergency Medical Responder (EMR) level. This classification is taking the place of First Responder so it sounds as though officers on the street have been trained to that level. This appears to establish “duty”.
Breach of duty is exactly what it sounds like, not living up to your duty. The important thing to note is that breach of duty can occur with or without your knowledge. If you consciously make a decision to breach your duty that counts. Unknowingly breaching duty occurs when an individual acts in the opposite manner as a “reasonable” person with similar training in a similar situation. This appears to be what happened in Bakersfield. Looking through the Scope of Practice (PDF link) for EMR, “manual stabilization of cervical spine injuries” is listed as the first bullet point under trauma care. This would indicate to me that the officer was trained to recognize and stabilize these kinds of injuries and did not act reasonably based on his training.
Causation means that the action (or inaction) of the individual is what resulted in injury. This is were I might take issue with the settlement in this case. The collision was severe enough to kill the driver of the vehicle the patient was in. The CHP stated during the case that the girl was “hanging by her neck from the shoulder belt of the car and appeared to be in distress” [1]. At 20 months, a girl in the 50th percentile for weight would weigh about 25lbs [2]. This is within the range for most rear-facing infant seats and certainly in the range for a forward facing car seat. For her to be tangled in the shoulder belt would indicate to me either a massive force of collision or improper use of restraints. Does this mean that the actions by the officer didn’t worsen the condition? No, but I would find it difficult to prove that she wasn’t paralyzed first.
Damages in a negligence case means that there was some injury caused that is worthy of compensation. If you were helping a passenger out of the front seat of the ambulance and she slipped, stubbing her toe, it would be difficult (but not impossible) to be ruled as negligent because there would be no long term issues resulting from her stubbed toe. In this case, however, damages are clear, the patient will require extensive medical treatment and daily care.
REFLECTIONS
One important point to note is that this pay out by the CHP is based on a settlement meaning that the case did not reach a judgement at trial. Whether the compensation awarded would have been different is anyone’s guess.
A few quotes from the article caused me concern. One of the paramedics on scene testified that “he didn’t want to touch the girl because he he was concerned about being held responsible for any spinal injuries” [1]. This is ridiculous to me. If you can testify under oath that you don’t want to touch an obviously critical patient because you are worried about being blamed for an injury, I suggest another line of work. This is the same as not wanting to perform CPR on a full arrest patient for fear of being blamed for the cardiac arrest. Enough said.
Lastly, there is the statement: “The CHP also said an ambulance crew didn’t have the right size equipment for Martinez and directed the officer to carry her to them.” [1] For a child this size, a Pedi-board is obviously indicated. If the crew did not, in fact, have the correct equipment with them, this is a sobering reminder of why you need to be very sure that your vehicle is properly stocked. You can often get away with “immobilizing” an infant in their car seat, but there are certainly situations where that is not appropriate.
Hopefully this has served as a good review of what constitutes negligence. If you have any questions or comments, please feel free to drop me a line.
CITED ARTICLES
[1] - Mayer, Steven: “Six-year-old Bakersfield girl gets $4.5 million from CHP”. Bakersfield Californian 2011 May 24, Web – accessed 2011 May 26.
[2] – KeepKidsHealthy.com – Growth Charts, Girls Birth to 36 months
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Clarity of documentation
Posted by Patrick Lickiss on Mar 9, 2011 in General, Legal | 0 comments
I haven’t see this one yet, but I assume it’s just a matter of time.
Clear documentation is a key in our line of work. Not only does the quality of your chart potentially impact the long-term care of the patient, but it could protect your license and career in the event of litigation.
THE HOSPITAL
Leaving a detailed patient care report at the receiving facility should be considered part of the turnover of care before clearing to go back into service. Often, patients are unable to answer questions on their own, or small bits of information may get lost along the way. We work hard on scene to gather as much information as possible and it is our duty to pass that information on. Consider, for instance, the stroke patient who is suffering from aphasia. He can’t articulate to the ED staff that time of onset of his symptoms. But by accurately charting that information or recording contact information for witnesses, you can facilitate the treatment of this time sensitive patient.
THE COURTROOM
Consider also the example frequently given in EMT and paramedic programs: There you are, sitting in a courtroom, wearing a suit for the first time since your hiring interview. Projected on a huge screen behind you is your PCR. Piece by piece, the attorney tears your chart apart. By the time you’re done, you aren’t sure who doubts your medical judgement more, the jury, or you.
Sure I’m approaching this in an overly-dramatic fashion. I’ve been fortunate enough (knock on wood!) to avoid testifying so far. But this story is all too common. The fear of litigation is a real one and writing a competent, clear and consistent PCR is one of your best methods to combat a great deal of stress.
HOW-TO
There are a variety of examples of how to write a good PCR (here’s an oldie but goodie) but with systems moving to ePCR, the best example may be one from your own system. Data entry methods and final print copies vary so much from program to program that while guidelines may still apply, the exact method can be vastly different, even among agencies in the same county or state. You know a practitioner who performs good documentation at your service, so ask to see some of his or her PCRs. Many electronic PCR programs have the ability to print copies which are stripped of patient identifiers (called Intern PCRs in my system). This will allow you to read narratives and treatment sections and incorporate the aspects which work best for you.
When I first started doing QA/QI work, one of my tasks was reviewing “critical” PCRs for completeness. By reading PCRs written by basically every paramedic at my service I was able to vastly improve my documentation. And that was without taking a single class or attending one documetation workshop.
So how about you? What have you done in your service to improve your documentation? Chart review? Peer-based run reviews? Anything else?
Image via Married to the Sea (a hilarious read!)
Zen and the Art of Patient Refusals
Posted by Patrick Lickiss on Oct 14, 2010 in Assessment, General, Legal | 2 comments
In light of the Missouri crew who AMA’ed a patient who later suffered a cardiac arrest from a pulmonary embolism, I thought it might be a good idea to review the basics of patient refusal. The merits of what was or wasn’t done for the patient have been well covered on both the EMS Garage Podcast and on EMS in the New Decade. I would encourage you to take a moment to listen and read those resources at your leisure.
“IT’S A BAD THING”
When listening to the EMS Garage podcast the other day, a particular statement was made which caught my attention. To paraphrase, the idea basically was: “If you have to respond back to an address, it’s a bad thing”. This seems like a fairly universal line of thinking. I had one of these calls a while back and it certainly was not one of my finest moments. Sometimes, however, the patient WAS assessed and treated properly and their condition simply progressed. Or what if the patient adamantly refused to go in spite of having a real medical problem? In the case is Missouri, it sounds like the first crew didn’t perform a thorough assessment and then stepped outside their scope of practice when suggesting treatment and transport options, but this isn’t always the case.
WHAT IF THE PATIENT WAS ASSESSED?
Let’s assume for a moment that you’re on scene of a call. You’ve assessed the patient in a thorough and appropriate manner and he simply doesn’t want to go. You have a bad feeling about leaving the patient but since we’re not in the kidnapping business, you move ahead with the refusal paperwork. What can you do to protect yourself and ensure that your documentation is thorough? The following is an approximation of what I do in my own practice and I hope you find it useful.
ACTUALLY ASSESS THE PATIENT
So this seems a bit redundant, but there are plenty of caregivers out there who will AMA a vehicle accident patient without performing a hands on assessment, or a dizziness patient without performing a 12 lead ECG. These patients, more than just about any other (from a liability standpoint) need a complete physical assessment. Take a full set of vital signs. Get a SAMPLE history. Think of the worst case scenario and rule out those causes. This may mean a 12 lead ECG, the State of Maine exam or the Cincinnati Prehospital Stroke Scale. Make sure that you are proficient in these skills and assessments and document them accordingly.
ENSURE THAT THE PATIENT IS CAPABLE OF REFUSING
This item varies from system to system and between provider agencies. At any rate, assess the patient’s level of mentation and make sure that they meet the criteria under which you operate. Filling out that AMA form for a patient under the influence of alcohol who has a GCS of 13 is probably not the best idea.
EXPLAIN THE BENEFITS AND RISKS
Most providers explain the risks of refusing to the patient, but not all explain the benefits of transport. Make sure that the patient is not only told about the benefits and the risks but that he understands them. This means using terminology that a lay person can understand. Too often we use correct medical terminology that simply goes over the heads of our patients. If the patient has chest pain, explain that you’ve performed as thorough an examination as you can in the field but that the hospital has other tools which can provide a better picture of what may be causing that chest pain. Advise him that if he doesn’t go to get checked out at the ED that his condition could worsen. If it is a problem with his heart he could end up suffering permanent damage from a heart attack. Once again, make sure that the patient actually understands what you’re telling him. This makes is extremely difficult to properly perform a refusal when there is a language barrier present.
OFFER TRANSPORT
Again, this one seems like a no brainer, but just make sure that you clearly state it. Something along the lines of “We’re here and we’re happy to transport you to the emergency room so that they can completely assess you and we can provide care on the way” goes a lot further than something like “We can take you if you want”. Just to be safe I’ll generally offer transport before and after explaining the benefits and risks to the patient.
FIND OTHER OPTIONS
If the patient isn’t going to go with you, figure out what other options they have. Generally, they can call 911 and ask for you to come back, find their own way to the ED or follow up with their regular doctor. Explore why they don’t want to go the ED via ambulance. Maybe it’s a concern about a particular receiving facility; maybe it’s a worry about money. At any rate, make sure that the patient has resources available in the event that something about their status changes. Should you approach a patient differently when they live at home alone versus living with someone who can keep an eye on them? Absolutely. Do what you can to act in the patient’s best interest, even if you aren’t transporting them to the hospital.
HAVE BACKUP
While it varies between systems, most have individuals to contact if something is abnormal about a patient refusal. This may mean contacting medical control or calling a supervisor. In certain instances, you may need to involve law enforcement. That has, however, been known to backfire. Now I’m not saying that this will happen every time you involve law enforcement, but remember that each agency has different priorities on scene.
CONCLUSION
Ultimately this issue comes down to customer service. You want to treat your patient with respect but make it clear that based on your COMPLETE assessment that you are recommending that they go with you to the ED and that they are refusing. Polite and firm is the name of the game. By advising the patient correctly, and properly documenting the advisement and the patient’s responses, you can reduce your liability and ensure that the patient is treated correctly.
NOTE: I’m not an attorney, nor am I an expert on documentation. Check with your agency or overseeing body to make sure that you are compliant with local policies and procedures.
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Another EMS horror story…
Posted by Patrick Lickiss on Jun 28, 2010 in Assessment, Current Events, Legal, Treatment | 1 comment
UK Paramedic Told Dying Man to Walk to Emergency Vehicle
So to summarize, a paramedic working on a Rapid Response Vehicle, is dispatched to a chest pain call, performs an initial exam, determines that the patient is having an asthma attack, and tells that patient that he must walk to the vehicle so that he can be transported to the hospital. While walking out to the vehicle, the patient collapses in cardiac arrest.
The article goes on to detail the disciplinary hearings and the subsequent findings against the paramedic, but I’d like to discuss the alleged call itself first. The first paragraph of the article reads:
“A patient suffered a heart attack and died on his doorstep after a paramedic wrongly diagnosed asthma – then told him to walk to an emergency vehicle.”
My first issue with the call, or perhaps the article, is the fact that a patient diagnosed with an asthma attack, rather than an active MI, is walked from his residence to a vehicle in the first place. All too often, responders walk patients with significant medical complaints like SOB, seemingly not understanding that even a small amount of exertion can exacerbate the patient’s condition significantly.
The root cause of the issue appears to be a lack of organized assessment on the part of the responding paramedic. After arriving on scene, he did not bring a cardiac monitor into the residence and did not perform a secondary examination, apparently not checking vital signs either. The paramedic fully intended to transport the patient to the hospital in the Rapid Response Vehicle, leaving no way for the patient to be monitored en route to the hospital and likely not receiving any treatment.
This case underscores the necessity to treat every patient as though they are “big sick” until proven otherwise. Had the responding paramedic performed a full ALS assessment on a patient with an ALS complaints, he would have undoubtedly called for a transport ambulance and initiated proper care for the patient. While it is still possible that the patient may have died, at least he would have been provided with proper care and subsequently a fighting chance. This case is a stark reminder of the complacency and downright laziness which exists in EMS. It is a sobering reminder that we have a responsibility to hold our coworkers accountable.
On the subject of accountability, the disciplinary action taken against the responding paramedic seems somewhat inappropriate. The reporter seems surprised that the paramedic was “allowed to keep his job by the regulatory board” . I am a firm believer that most CES-related issues in EMS can, and should, be corrected by educational action. We are all humans and we all make mistakes. I fully advocate providing the opportunity to learn from those mistakes. That being said, while educational deficiencies can generally be corrected, personality deficiencies sometime can not. There are simply people who are not suited to work in EMS. The kind of paramedic who would knowingly walk an asthma patient (regardless of an acute MI) to a non-transport vehicle may simply not have the requisite personality to continue a career in EMS.
So what was the disciplinary action taken against the paramedic you may ask? A five-year caution order. The most frustrating part of the article is a statement made by the panel spokesman:
“…saying that problems with Mr Galligan’s patient care meant they had to take some action, but observing that placing conditions on him would be impractical as he worked alone.”
As I stated before, I’m all for correcting educational deficiencies, but allowing a paramedic who made a mistake such as this to continue to work alone seems ludicrous. Working solo on a Rapid Response Vehicle seems to be a shift that should be reserved for highly trained, clinically sound paramedics. Using the argument that further oversight would be impractical simply means that the paramedic should be placed on a shift where such oversight is practical.
It seems to me that the Health Professions Council dropped the ball. I will add the caveat that I have no immediate knowledge of the call in question, nor the subsequent investigation, and I am sure that there are other aspects to the situation than what are stated in this single article. I still believe, however, that we are standing at a crossroads in the future of EMS and that if we allow apathy and laziness to overwhelm clinical judgement and a desire for excellence, we are going to wind up being relegated to the position of “ambulance drivers” before we know it.
Okay, enough of me on my soapbox, now it’s your turn. Do you feel the right decision was made from a disciplinary standpoint? What is your opinion on education vs. punishment in these kinds of cases? What can we do to weed out/inspire to excellence these types of coworkers? I’m looking forward to hearing your thoughts.
To stop or not to stop?
Posted by Patrick Lickiss on Jun 16, 2010 in General, Legal | 2 comments
So today I’d like to change things up a little bit. Rather than tackling a specifically clinical issue, I’d like to present a moral/ethical/legal conundrum. This issue came to mind the other day when, on my way home from work (off-duty and clocked out), I approached the scene of an MVA on the freeway. I tend not to stop at these types of incidents, but as soon as I saw the scene (rolled over vehicle with possible entrapment with no responders on scene) I was on the phone to our dispatch center to see if they had a unit en route. Since the accident was news to them, I requested they send resources and told them I would call back with an update. After pulling over, I performed an initial assessment and, finding the patient remarkably uninjured but still pinned in the vehicle, waited until further resources arrived.
After driving away from the scene of the accident, I marveled that in my tenure in EMS this was only the third accident I had ever stopped at while off duty. All three of those incidents were fairly serious looking and had happened recently with no one on scene. I remembered briefly hearing about recent changes to the California “Good Samaritan” law which had closed some legal loopholes so I started researching when I arrived at home. It turns out that in August of 2009, the Governor (the Terminator himself for those of you from out of the state) signed AB 83 which closed a loophole in the existing law withholding protection from those who stop and render “non-medical” aid to those in need (1). Nice to know that if I were to stop and help someone change a flat tire I would be as protected as if I were rendering medical care. A quick search of the California EMSA website revealed that Chapter 9 of Division 2.5 of the California Health and Safety Code addresses directly the limitation of civil liability. I’ll save you from the legal ramblings, but I would like to quote one section which sums up the protection afforded to off-duty EMS workers:
1799.102. (a) No person who in good faith, and not for compensation, renders emergency care at the scene of an emergency shall be liable for any civil damages resulting from any act or omission. The scene of an emergency shall not include emergency departments and other places where medical care is usually offered. This subdivision applies only to the medical, law enforcement, and emergency personnel specified in this chapter. [Amended by AB 83 (CH 77) 2009.]
The rest of the chapter goes on to speak to more specific situations, but the take-home lesson is this: as long as care is rendered “in good faith” and is not grossly negligent, the responder rendering the care is protected from civil damages. This is certainly reassuring. A quick review of medical legal terms shows that for negligence to be proven, four things have to occur:
- There is a duty to act
- There is a breach of that duty
- The breach causes an affect
- Damage has been inflicted to another (2)
Now as I understand it, at least in California, providers do not have a duty to act unless they are being paid or are volunteering in an official capacity. Since this is the case, stopping at an accident scene off-duty is entirely voluntary. Once you contact a patient, of course, you have a duty to continue to render aid until providers arrive.
So from a purely legal standpoint, it seems that we are protected (assuming you live in California) when we stop and help at on-view accident scenes. Stopping at said scenes is also entirely voluntary and we assume no legal liability for just driving on by.
Another interesting issue surrounds the equipment available. In most cases, the best thing for the scene of an accident is a pair of gloves and something to write with; triage and assessment are going to be the most helpful for later-arriving responders; but what about more advanced equipment? At least when I used to work there, Sacramento County had a provision in the protocols allowing off-duty paramedics to carry intubation equipment for establishing advanced airways. Needless to say (for those who know me) I did not exercise that right.
Now comes the part where I would love some input. Do you stop at accidents when you are off-duty? How do the legal issues differ in your area? What do you carry in your vehicle in the way of supplies? Does your LEMSA allow the use of ALS equipment off-duty? What is your view when coming onto a scene with bystanders rendering aid while on-duty? Do we have a moral obligation to stop more often to render aid not just when it “looks serious”? I’m interested to hear your opinions.
NOTE: The opinions expressed here are those of the author alone and do not represent the views of any company or organization. Use common sense and check with your local accrediting agency before making treatment decisions based on anything written here. This article is not a substitute for protocols or policy and procedure manuals. Additionally, I am not attorney and nothing stated in this article should be interpreted as legal advice.
CITED RESOURCES
1. http://democrats.assembly.ca.gov/members/a42/newsroom/20090806AD42PR02.htm
Life in the public eye…
Posted by Patrick Lickiss on May 14, 2010 in Current Events, Legal | 2 comments
Putnam County settles wrongful death suit against EMS Squad for $85k
This suit was settled following a 2006 call in which two paramedics responded to a call for a 28 year old asthmatic experiencing shortness of breath. The suit, filed by the patient’s sister alleged that the responders did not provide timely assessment and care, walked the patient down two flights of stairs and “acted as if it was a bother or nuisance to them to have to respond to the emergency call.”
After being transported to the emergency room, the patient died of acute respiratory failure.
The issues with this call are two fold:
First there is the clinical aspect. Without having read testimony and court documents, it seems likely based on the allegation of lack of timely assessment and treatment, that the responders either did not treat the patient, waited too long to treat the patient or were not aggressive enough with their treatment. In all likelihood, it is probably a combination of the latter two events.
More shocking, however, is the fact that the patient was walked down two flights of stairs. I’ll go out on a limb and say that it’s never appropriate to walk a respiratory patient down stairs. I’m sure there are a few situations floating around when it might be warranted, but those are definitely few and far between. Ultimately, the decision to walk a respiratory patient to the gurney means either laziness on the part of responders or an inability to determine a patient’s severity. I honestly don’t know which possibility is more frightening.
The second issue of this call is the customer service aspect. In his editorial note about the case, Art Hsieh brings up a great point: “Patients remember kindness, courtesy and respect — and they remember inappropriate behavior even more.” Everyone reading this can probably recall a time when they provided excellent patient care but may have not provided excellent customer service. When complaints come in they often do not relate to clinical care, but to interpersonal conflicts.
At the end of the day, no matter how we act towards our patients on scene, we still have a legal obligation to transport them to the hospital. That being the case, doesn’t it just make more sense to treat them with kindness and respect? It’s certainly a lot less stressful for the crew members to just be polite. Now don’t think I’m getting up on my high horse, I’m certainly not saying that I’ve never rolled my eyes on scene or acted annoyed, what I’m asking is, what does it really accomplish?
Remember that we are very much in the public eye while doing our jobs. It’s important to remember that we don’t just treat the patient’s medical complaint, we ultimately treat the whole patient. Cases like this and the large settlement associated should serve as a wake-up to EMS practitioners everywhere.
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