Unfortunately no, but this story had me going. Turns out that EMS agencies in Portland, Oregon are going to be studying “whether cardiac arrest drugs help or hinder”. That headline gave me hope that we were finally studying if all the ACLS drugs benefited or harmed patients when looking at neurological outcomes. Turns out we’re not. We’re studying whether Amiodarone, Lidocaine, or a placebo results in better outcomes. Now don’t get me wrong, this is a step in the right direction. Now that being said, the article references the fact that research has already shown Amiodarone to be no more effective than a placebo. But, if memory serves, that study looked at ROSC, not neurologically intact outcome. That being the case, this study IS moving in the right direction.
My question remains, however, why can’t we do the same study with epinephrine? On the face of it, this study protocol appears to be one which could be easily transferred to epinephrine. Using syringes marked only with a barcode so that researcher can later link a certain medication or a placebo to a given patient. When I started reading the article comments, however, I realized why we can’t study epinephrine. We haven’t bothered to teach the public. Heck, we haven’t even bothered to teach the medical community. Many of the comments, including some from those who identified as medical professionals, launched into tirades about lawsuits resulting from withholding “standard care”. The fact is, as long as people (both those in the public and the medical community) assume that our “standard” treatments are based on facts, our hands will be tied. This dedication to tradition for tradition’s sake may be killing our patients.
We are forced to follow outdated modes of treatment because we haven’t taken the time to educate our own communities about what those treatments are based on. While there will always be a subset of the population unwilling to participate is these types of programs, aggressive public (and medical) education campaigns may help to mitigate some of those issues. Researchers are offering the public free “No Study” bracelets if they want to opt out. It will be interesting to see, when all things are said and done, how many took them up on that offer and if they have trouble getting an acceptable sample size.
What do you think? What would be the most effective design for a study looking at the benefit or harm of ACLS drugs? Should patients or family have to consent for this type of study? How can we effectively educate the public about why and how we treat them? Do you work for one of the agencies in this study? Let me know in the comments.
Last week it was reported that a Central Valley, California man was arrested and charged with failing to comply with his tuberculosis treatment. To my knowledge, there aren’t many cases where Public Health can mandate care, but TB is certainly one of them. Interestingly the article stated that county officials had also charged a woman for knowingly giving syphilis to her partner and refusing treatment. The county concludes that legal action is an extension of medical care. A bold, but likely controversial statement. What do you think?
While you ponder the answer to that question, I’ll leave you with a quote from the article:
He failed to self-administer the drugs on one day, telling a nurse he had gone on an alcohol binge and taken methamphetamine and didn’t want to hurt his liver…
Yup, wouldn’t want that medication to harm your liver…
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” . At 20 months, a girl in the 50th percentile for weight would weigh about 25lbs . 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.
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” . 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.”  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.
 - Mayer, Steven: “Six-year-old Bakersfield girl gets $4.5 million from CHP”. Bakersfield Californian 2011 May 24, Web – accessed 2011 May 26.
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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.
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.
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.
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!)
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.
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.
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.
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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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.