# Dying patient left on apartment floor



## NomadicMedic (Mar 31, 2021)

State board cites 7 Kan. responders for failing to transport patient to hospital
					

Though injury was deemed "incompatible with survival," bodycam footage and records show patient was alive for hours before transport to hospice




					www.ems1.com
				




thoughts?


----------



## DrParasite (Mar 31, 2021)

I read this last night.... Couple thoughts:
1) this is BAAAAAAD.  The optics are horrible. But just because it looks bad, and people's emotional response is highly negative, doesn't mean it was an incorrect clinical decision.
2) "[Sedgwick County EMS Medical Director Dr. John Gallagher] went to the man's downtown Wichita apartment and decided he was "unsalvageable" and should be left to die."
3) "The Medical Society's EMS Physicians Advisory Committee reviewed the case shortly after this tragic incident occurred," Brownlee said. "The committee of emergency medicine physicians unanimously concluded the EMS providers delivered appropriate care."
4) "Two months after the call, Sedgwick County consolidated its EMS services and the Office of the Medical Director, placing Gallagher, a physician, as the top official in the county's EMS system."
5) The EMS supervisor was on scene and directly contacted the medical director.  So the field paramedics were utilizing their chain of command and follow their direction.  multiple times.

Some other thoughts
1) All paramedics work under the license of the medical director.  The medical director made a call, so if a paramedic overruled or disregarded the medical director, they would be practicing medicine without a license
2) With GSW to the head, maybe brain matter was showing... does anyone seriously think the patient was going to live?  and if the MD says the patient is not viable, isn't it their prerogative to make that decision?

the Kansas Board of Emergency Medical Services has no authority over the medical director, which is why they are going after the field crews.  , but I do agree with them on one thing: there should be an investigation into Dr. John Gallagher's actions.  Even if the Medical Society's EMS Physicians Advisory's committee review wasn't good enough.  And if the investigation confirms that Dr. Gallagher's actions were appropriate, then the Kansas EMS board should drop all charges against the EMS providers involved in the calls, and offer them formal apologies for their erroneous judgments against them.


----------



## mgr22 (Mar 31, 2021)

Here are two paragraphs that stood out to me:

"Charges include falsifying information, disregard for patient well-being and dignity, failing to provide patient care, unprofessional conduct and not following protocol.

"Gallagher (an MD) supervised the call that day along with Sedgwick County paramedic Timothy Popp. Gallagher is not facing disciplinary action."

Among those charges, "falsifying information" and "not following protocol" should be specific and the easiest to sustain or refute. And if Dr. Gallagher was providing medical control online and later on-scene, I think that's where the ultimate responsibility should lie.


----------



## GMCmedic (Mar 31, 2021)

We had a very similar situation locally and I can tell you that nobody wins in this. 


I don't believe that body cam footage is adequate enough to determine punishment for fire. It's very plausible that the patient was clamped down so tight they didn't have palpable pulses, and labored breathing doesn't really say much beyond respirations were present. 


That said, I'm not familiar with Kansas rules and regs.

In my opinion absent falsified information, the medical director is responsible.


----------



## E tank (Mar 31, 2021)

From the accusations, seems to me that there was no provision in the local protocol to allow for "end of life care" determination by the doc. Really odd story...given the exact same injury in an accidental discharge or a robbery, would they have made the same decision?

Kind of an aside, but suicide/euthanasia have been making their way into main stream thinking and a very particular narrative about them is gaining favor in medical (physician) training and governmental settings. 

Is this kind of thing a thing? Kind of breathtaking...


----------



## Peak (Mar 31, 2021)

Not to sound like a vulture but that’s a heart, two lungs, liver, two kidneys, and gut that were slowed to die in vain instead of potentially being harvested.


----------



## CCCSD (Mar 31, 2021)

One quick BLS ride and this never would have been an issue...


----------



## Jim37F (Mar 31, 2021)

So the patient had injuries incompatible with life, yet they found a pulse after doing a round of CPR? Why did they even start CPR in the first place?

But with a pulse, with our without CPR, this whole mess would have been avoided by simply transporting. 

But otherwise it sounds like the field crews did follow their Supervisor and Medical Director instructions. And not like offline protocols or online instructions via phone/radio, but by the Doc being there in person, they were following their chain of command so if you wanna be upset with the Doc or Supervisor do so, but not the crews.

Now the other charges are concerning. They talk about charging people with falsifying records or acting inappropriately with the patient, etc. Def some serious stuff right there.... and the article makes no effort whatsoever to support those charges. It sounds more like someone just fired a shotgun blast of charges just to see if something would stick, not because they had any evidence to support those charges in the first place.

THAT is concerning to me. I didn't get any sense that anyone was trying to hide or falsify anything, just that it was a bad call with a bad outcome. 
Sounds like it should be more of a case of "EMS apologizing and clarifying procedures that yes he was gravely injured, and no trauma team would change that, be he wasn't dead just yet, so it would have been better to transport" versus dragging the Medics names thru the mud and throwing career ending charges at them...


----------



## CCCSD (Mar 31, 2021)

When in doubt, transport.


----------



## E tank (Mar 31, 2021)

Peak said:


> Not to sound like a vulture but that’s a heart, two lungs, liver, two kidneys, and gut that were slowed to die in vain instead of potentially being harvested.


Not necessarily...if he doesn't show brain death criteria, he can't be harvested. Intubated he could last indefinitely. Tissue harvesting after death, sure, but not vital organs...


----------



## Tigger (Mar 31, 2021)

This is uh....wild all around. “Hey doc I don’t think he’s dead yet, cool if I give some v high dose ketamine in the meantime?”


----------



## EpiEMS (Mar 31, 2021)

Unreal. Wow. I'd be curious to read the autopsy report, assuming one was performed.

I'm not convinced that following the Medical Director's orders necessarily protects from liability...particularly if they are in contravention to good judgement. That said, perhaps the issue here is a subjectivity in determination as to what a "lethal injury" is?


----------



## E tank (Mar 31, 2021)

Tigger said:


> This is uh....wild all around. “Hey doc I don’t think he’s dead yet, cool if I give some v high dose ketamine in the meantime?”


Yes...missed that among all the other jaw droppers...my opinion, but this thinking is a direct consequence of physician assisted suicide/euthanasia campaigns that are taking some states by storm.  Someone on a scene offers to snuff a patient? Unreal.


----------



## Tigger (Mar 31, 2021)

E tank said:


> Yes...missed that among all the other jaw droppers...my opinion, but this thinking is a direct consequence of physician assisted suicide/euthanasia campaigns that are taking some states by storm.  Someone on a scene offers to snuff a patient? Unreal.


Who knows what the route cause is here, but 500mg (x2) is not really a comfort dose. Not much of a euthanasia med either. The whole thing just seems like it just spiraled out of control. Involved medical direction is important but it seems like in this case that some excessive decisions by the physician played a role here. Still very unclear as to why the control doc would leave the hospital to mitigate this, what is the best case scenario he was looking for?


----------



## CCCSD (Mar 31, 2021)

Ego.


----------



## Peak (Apr 1, 2021)

E tank said:


> Not necessarily...if he doesn't show brain death criteria, he can't be harvested. Intubated he could last indefinitely. Tissue harvesting after death, sure, but not vital organs...



We can harvest and reperfuse many organs after cardiac death. Kidneys, livers, and pancreas are pretty straightforward and most OPOs can do this. In some cases we can get the heart and lungs, but these are far more challenging.


----------



## DrParasite (Apr 1, 2021)

Tigger said:


> Involved medical direction is important but it seems like in this case that some excessive decisions by the physician played a role here. Still very unclear as to why the control doc would leave the hospital to mitigate this, what is the best case scenario he was looking for?


Some systems (including my own) have an EMS medical director who frequently responds to the scene, in a marked vehicle.  the medical director is different than medical control, and is typically a full time employee of the EMS agency.  The county medical director of my county (and his two deputies) both have take home cars, as did the former medical director of the agency when I worked in NJ, and it's not uncommon for him to show up on a scene.  esp weird or unusual ones in the city limits

I don't know if I agree with your assessment of "excessive decisions by the physician" especially when the field crews contacted the doc for advice/orders/guidance.  But giving ketamine because he's not quite dead yet... I mean, I understand why (alleviate suffering, not contradict the medical director, etc), but ooo boy...


----------



## Tigger (Apr 1, 2021)

DrParasite said:


> Some systems (including my own) have an EMS medical director who frequently responds to the scene, in a marked vehicle.  the medical director is different than medical control, and is typically a full time employee of the EMS agency.  The county medical director of my county (and his two deputies) both have take home cars, as did the former medical director of the agency when I worked in NJ, and it's not uncommon for him to show up on a scene.  esp weird or unusual ones in the city limits
> 
> I don't know if I agree with your assessment of "excessive decisions by the physician" especially when the field crews contacted the doc for advice/orders/guidance.  But giving ketamine because he's not quite dead yet... I mean, I understand why (alleviate suffering, not contradict the medical director, etc), but ooo boy...


I too work in such a system. Ketamine is not long acting nor is 500mg a pain dose. I ask again what outcome the doctor was seeking here by responding to the scene. This was not a complex call.


----------



## Carlos Danger (Apr 1, 2021)

Tigger said:


> I too work in such a system. Ketamine is not long acting nor is 500mg a pain dose. I ask again what outcome the doctor was seeking here by responding to the scene. This was not a complex call.


500mg isn’t a pain dose but it’s the dose you would want given to you in a similar scenario, that is assuming one of the many more appropriate drugs are unavailable. 

Super weird situation.


----------



## DesertMedic66 (Apr 1, 2021)

What on earth is going on in that system? Why are there so many inconsistencies with their report? Why would you not transport this patient to a hospital that is 5 minutes away? Why would you have a medical director respond to a scene that is less than 5 minutes away from an ED?

So instead of transporting the patient, who is still alive, to the ED where they have established palliative care process, they spend over 5 hours on scene just watching this guy cough/vomit/move his extremities.

Makes you wonder what other extremely shady things have occurred without being investigated.


----------



## EpiEMS (Apr 1, 2021)

Anybody found the documents from the KS EMS board? I can’t find a thing.


----------



## MMiz (Apr 1, 2021)

Wild story.

With four paramedics on scene in contact with medical control, I wonder what I would have done as a lowly EMT.


----------



## mgr22 (Apr 1, 2021)

MMiz said:


> Wild story.
> 
> With four paramedics on scene in contact with medical control, I wonder what I would have done as a lowly EMT.


Maybe if they'd listened to you (the MD too), none of the stupid stuff would have happened. I'm serious. Lack of common sense sounds like the presenting problem.


----------



## ffemt8978 (Apr 1, 2021)

mgr22 said:


> Maybe if they'd listened to you (the MD too), none of the stupid stuff would have happened. I'm serious. Lack of common sense sounds like the presenting problem.





MMiz said:


> Wild story.
> 
> With four paramedics on scene in contact with medical control, I wonder what I would have done as a lowly EMT.


I don't have a hard time seeing that if was two basics on the call, it would have been a load and go to the hospital and let the ER deal with it.


----------



## mgr22 (Apr 2, 2021)

ffemt8978 said:


> I don't have a hard time seeing that if was two basics on the call, it would have been a load and go to the hospital and let the ER deal with it.


Yep. How bad would that have been, considering the outcome?


----------



## Bullets (Apr 2, 2021)

Tigger said:


> I too work in such a system. Ketamine is not long acting nor is 500mg a pain dose. I ask again what outcome the doctor was seeking here by responding to the scene. This was not a complex call.


Yeah, but is a GSW, and that always brings a crowd


----------



## EpiEMS (Apr 2, 2021)

MMiz said:


> Wild story.
> 
> With four paramedics on scene in contact with medical control, I wonder what I would have done as a lowly EMT.



Hopefully gotten there before then & transported!

In all seriousness, this is much easier as a BLS call:

Observe patient with life threat (likely a terminal wound, based on description) and present VS. Do the usual rapid assessment. Patient to Reeves, Reeves to ambulance stretcher, run hot to nearest trauma center. No suit, no discipline.

Not to get on a BLS first soapbox, but in populated areas, trauma usually should be BLS...


----------



## Carlos Danger (Apr 2, 2021)

While clearly unconventional, I don't think it's necessarily unreasonable that an EMS physician who determined that a patient's injuries were incompatible with life and presumed that the patient would die very soon might choose to direct the administration of analgesia and anxiolysis in lieu of transport for what would be futile care. It's a different thought process and approach, but it makes perfectly good sense from a certain perspective. When things (inevitably) didn't go as planned because the patient was still alive and moving several later, that's really when things complicated and weird. 

Is that not the essence of what happened?


----------



## silver (Apr 2, 2021)

Carlos Danger said:


> While clearly unconventional, I don't think it's necessarily unreasonable that an EMS physician who determined that a patient's injuries were incompatible with life and presumed that the patient would die very soon might choose to direct the administration of analgesia and anxiolysis in lieu of transport for what would be futile care. It's a different thought process and approach, but it makes perfectly good sense from a certain perspective. When things (inevitably) didn't go as planned because the patient was still alive and moving several later, that's really when things complicated and weird.
> 
> Is that not the essence of what happened?



And thus we get to what many ethicists emphasize, don't judge decision making on the outcome. I think based on the information at hand, the EMS physician's determination was a reasonable and ethical one.


In the end though it makes you wonder, should there be more guidance in terms of providing comfort care in the field.


----------



## Tigger (Apr 3, 2021)

Carlos Danger said:


> While clearly unconventional, I don't think it's necessarily unreasonable that an EMS physician who determined that a patient's injuries were incompatible with life and presumed that the patient would die very soon might choose to direct the administration of analgesia and anxiolysis in lieu of transport for what would be futile care. It's a different thought process and approach, but it makes perfectly good sense from a certain perspective. When things (inevitably) didn't go as planned because the patient was still alive and moving several later, that's really when things complicated and weird.
> 
> Is that not the essence of what happened?


It is the essence, but it was not executed as such.


----------



## Jon (Apr 3, 2021)

mgr22 said:


> Here are two paragraphs that stood out to me:
> 
> "Charges include falsifying information, disregard for patient well-being and dignity, failing to provide patient care, unprofessional conduct and not following protocol.
> 
> ...


I agree 100%.

Apparently Dr. Gallagher is/was a member of the ethics committee that reviewed the case and found his conduct acceptable. Seems like a conflict of interest to me.


----------



## DrParasite (Apr 3, 2021)

EpiEMS said:


> Hopefully gotten there before then & transported!
> 
> In all seriousness, this is much easier as a BLS call:
> 
> ...


let's be realistic: no areas of this country are going to treat a GSW to the head as a BLS call.  I don't care how populated the area is, it's never going to be just two EMTs being dispatched.  Almost always ALS, sometimes a supervisor, maybe even a first responder from another agency. 

That being said, if it's you and me on the truck, and we decide to scoop and run, that is an option, but that doesn't mean it's the most appropriate.  if that GSW results in brain matter showing, should we even be transporting?  if we transport hot with a soon-to-be dead body and T-bone a bus full of kids, how bad will it look in the papers? on the witness stand when the lawsuit is filed?   And if our medical director buffs the call (because he was around the corner) and tells us not to transport because he is going to pronounce the patient as DOA, and we transport anyway, how does that muddy up the situation?

Just because we do transport, doesn't mean that was the appropriate action based on the patient's clinical presentation.


----------



## GMCmedic (Apr 3, 2021)

Carlos Danger said:


> While clearly unconventional, I don't think it's necessarily unreasonable that an EMS physician who determined that a patient's injuries were incompatible with life and presumed that the patient would die very soon might choose to direct the administration of analgesia and anxiolysis in lieu of transport for what would be futile care. It's a different thought process and approach, but it makes perfectly good sense from a certain perspective. When things (inevitably) didn't go as planned because the patient was still alive and moving several later, that's really when things complicated and weird.
> 
> Is that not the essence of what happened?



I think where the issue lies, is they committed themselves to the initial decision and were unable/unwilling to accept an alternative when things didn't go as planned. 

Even an hour in, if they had transported him, this PR nightmare could have been avoided.


----------



## Carlos Danger (Apr 3, 2021)

GMCmedic said:


> I think where the issue lies, is *they committed themselves to the initial decision and were unable/unwilling to accept an alternative when things didn't go as planned.*
> 
> Even an hour in, if they had transported him, this PR nightmare could have been avoided.


Exactly


----------



## FiremanMike (Apr 4, 2021)

I can’t imagine sitting on a scene with a man we resuscitated with sustained rosc and apparently purposeful movement and thinking “hell I need to call the doc and ask what to do!”

I’m all about termination of resuscitation, but I’m fairly certain ROSC and spontaneous respiration’s put you well outside of the appropriate criteria for TOR..

What a monumentally pathetic display of “EMS” and empathy for human suffering


----------



## EpiEMS (Apr 4, 2021)

Jon said:


> I agree 100%.
> 
> Apparently Dr. Gallagher is/was a member of the ethics committee that reviewed the case and found his conduct acceptable. Seems like a conflict of interest to me.



There's a lot of interesting research on why physicians don't discipline their own, I enjoyed this summary piece. This survey has some interesting stats as well. Also of interest -- Kansas has a very low rate of physician discipline (along with NY and CT, which I was a bit surprised by).

I think the broad point is that physicians (indeed, most professions) don't discipline their own because it makes them look bad collectively.



DrParasite said:


> let's be realistic: no areas of this country are going to treat a GSW to the head as a BLS call.  I don't care how populated the area is, it's never going to be just two EMTs being dispatched.  Almost always ALS, sometimes a supervisor, maybe even a first responder from another agency.
> 
> That being said, if it's you and me on the truck, and we decide to scoop and run, that is an option, but that doesn't mean it's the most appropriate.  if that GSW results in brain matter showing, should we even be transporting?  if we transport hot with a soon-to-be dead body and T-bone a bus full of kids, how bad will it look in the papers? on the witness stand when the lawsuit is filed?   And if our medical director buffs the call (because he was around the corner) and tells us not to transport because he is going to pronounce the patient as DOA, and we transport anyway, how does that muddy up the situation?
> 
> Just because we do transport, doesn't mean that was the appropriate action based on the patient's clinical presentation.



I'd agree with that first point -- almost always ALS, but probably not always rightly. OPALS showed no significant improvement in survival to discharge for AIS 4 & 5 injuries to the head & neck. With brain matter showing, for example, we may be right or wrong to transport -- my guess is wrong, but with respirations and a pulse, I'd be hard pressed to not give it consideration under the protocols I have read (NY, CT, MA, NH). The medical director aspect is much more complicated, for sure. It doesn't absolve the EMS providers, but it may mitigate culpability.


----------



## DrParasite (Apr 22, 2021)

an interesting legal perspective on this horrible situation









						A no-win situation: When medical director orders violate policy
					

Should Kansas providers face discipline for not transporting a patient who was breathing?




					www.ems1.com


----------



## luke_31 (Apr 22, 2021)

DrParasite said:


> an interesting legal perspective on this horrible situation
> 
> 
> 
> ...


David is pretty good at this sort of thing, especially noting all the mitigating factors involved.


----------



## E tank (Apr 22, 2021)

DrParasite said:


> an interesting legal perspective on this horrible situation
> 
> 
> 
> ...


A reasonable summary of the events that pretty much anyone with meaningful EMS experience could express. Why he brought up a so called 'Nuremburg defense' is odd. No parallel there at all as those individuals where expressly present in concentration camps to do harm. It's why 
they got out of bed in the morning, orders or no orders. Certainly not the case with this ambulance crew that was more or less ambushed with a disaster.


----------



## EpiEMS (Apr 22, 2021)

Very informative to see the legal take - though still unclear that the proper care was provided despite the local medical board’s conclusions. I’d like to read expert witness testimony if this goes to trial...


----------



## DrParasite (Apr 23, 2021)

E tank said:


> Why he brought up a so called 'Nuremburg defense' is odd. No parallel there at all as those individuals where expressly present in concentration camps to do harm. It's why they got out of bed in the morning, orders or no orders. Certainly not the case with this ambulance crew that was more or less ambushed with a disaster.


As the article states:





> Their defense was singular: they were just following orders. “I was just following orders” has become known, colloquially, as the Nuremburg Defense and it is not enough to shift liability completely. At most, it can be used in mitigation. Such would be the case here.
> 
> Indeed, the EMS providers were following the direct order of the most superior medical officer and that fact must be taken into account when considering the totality of the circumstances in mitigation. But was the order reasonable?





EpiEMS said:


> Very informative to see the legal take - though still unclear that the proper care was provided despite the local medical board’s conclusions.


Wouldn't the local medical board be an authoritative body to decide if proper medical care was provided?  They are a bunch of doctors, been doing the job for a while, and they are familiar with the local standards of care


EpiEMS said:


> I’d like to read expert witness testimony if this goes to trial...


I wouldn't because expert witness testimony is often worthless.  Why?  because the prosecution will bring out their expert, and the defense will bring out there's.  both are experts, and both are being paid to say what their side wants to hear.  So if you think the paramedics were right, you will like the defense's expert (and ignore the prosecution) and if you think the paramedics were wrong, you will like the prosecution's expert  (and ignore the defense).

Also remember, trials are not always about the facts of the case, but emotional opinions.  I don't LIKE that these paramedics let a dying man die, and didn't do something when his body refused to die.  But when the medical director (the guy whose license you operate under) gives you an order, what should you do?  Are you permitted to disregard it?  What about your operational supervisor, if they tell you do something, and you refuse, should you still be employed?  And if you take a direct order from your medical director, over the phone, and then in person, and you follow that order, should you suffer the consequences, or should the consequences fall to the person who gave the order?  Moreover, assuming that person was already investigated and found to have acted appropriately, now what?  a government body wants to punish the line staff for following the orders for a physician whose orders have been evaluated and judged as appropriate.

We (and the world) can whatif and coulda/woulda/shoulda the situation all day, but it doesn't change the facts of what happened, and it doesn't answer the basic question: should paramedics be disciplined for following the lawful orders (and clinically appropriate orders as per the local medical board) from their medical director if the patient doesn't have an outcome that you like?


----------



## NomadicMedic (Apr 23, 2021)

This entire case reeks of the, “everything is OK, right up until it’s not“ process. I’m sure that none of the participants in this case ever expected any of this to happen… But failure to prepare for instances like this, lead to disaster. 

I would gather that there is now some sort of SOG or protocol for the “non-salvageable patient that is not deceased on scene”

As almost everybody has mentioned, all of this would have been avoided had they simply picked the patient up and transported him to the emergency department where he would have died. Would that have been the best use of the resources? Maybe, maybe not… However an EMS crew would not have been on scene for five hours, watching a patient groan and breathe while he lay on the floor dying. At the end of the day, doing the right thing is the right answer. There was no way the crew was prepared to handle an eminently dying patient in this scenario that was presented. It’s just a sad situation that these providers, who experienced this horrible incident, are now being censured by the Bureau of EMS.


----------



## EpiEMS (Apr 23, 2021)

Just wanted to highlight a few points, @DrParasite, where I have a different view -- not intending to ignore your other points by any means, and certainly agree that expert witnesses are always biased (I want to hear both sides' best view and pick, frankly). 


DrParasite said:


> Wouldn't the local medical board be an authoritative body to decide if proper medical care was provided? They are a bunch of doctors, been doing the job for a while, and they are familiar with the local standards of care


Local medical boards are not the appropriate metric - not to mention the problems with self-regulation, the appropriate standard of care is national, not local. This has been an element of malpractice law that has changed over time.


DrParasite said:


> We (and the world) can whatif and coulda/woulda/shoulda the situation all day, but it doesn't change the facts of what happened, and it doesn't answer the basic question: should paramedics be disciplined for following the lawful orders (and clinically appropriate orders as per the local medical board) from their medical director if the patient doesn't have an outcome that you like?


Lawful doesn't mean correct. A clinically valid option isn't always ethically appropriate. In this case, the ethics are the question, more than anything else. Clinical and lawful are low bars. In this case, the providers failed in their duty to the patient to, among other things, provide appropriate palliation, which would best be performed by palliative care experts.


DrParasite said:


> Also remember, trials are not always about the facts of the case, but emotional opinions. I don't LIKE that these paramedics let a dying man die, and didn't do something when his body refused to die. But when the medical director (the guy whose license you operate under) gives you an order, what should you do? Are you permitted to disregard it? What about your operational supervisor, if they tell you do something, and you refuse, should you still be employed? And if you take a direct order from your medical director, over the phone, and then in person, and you follow that order, should you suffer the consequences, or should the consequences fall to the person who gave the order? Moreover, assuming that person was already investigated and found to have acted appropriately, now what? a government body wants to punish the line staff for following the orders for a physician whose orders have been evaluated and judged as appropriate.


You don't operate under the license of the medical director - that is a common false assumption. You operate under your state license (or state certification, if they call it that, but it is no different), subject to their supervision.  This is not the same thing. Furthermore, you have the professional and ethical obligation to act in contravention of orders if they are incorrect (after following the appropriate process to ensure you heard correctly).


----------



## CCCSD (Apr 23, 2021)

What if the crew transported him after they figured the Doctor was FOS and made bad patient care decisions?

You can’t go wrong transporting. Just document WHY.


----------



## DrParasite (Apr 23, 2021)

EpiEMS said:


> the appropriate standard of care is national, not local. This has been an element of malpractice law that has changed over time.


I think we need to agree to disagree on this one; while I do agree that the appropriate standard of care is national, the AHJ still sets decides what care that they will be applying to their area.  otherwise, all ambulances would be staffed identically, with identical protocols, and you could (literally) take a paramedic from a truck in NY and drop him or her on an ambulance in New Mexico, with no issues at all.  And we all know that is not the case.


EpiEMS said:


> Lawful doesn't mean correct. A clinically valid option isn't always ethically appropriate. In this case, the ethics are the question, more than anything else. Clinical and lawful are low bars. In this case, the providers failed in their duty to the patient to, among other things, provide appropriate palliation, which would best be performed by palliative care experts.


I will agree that lawful doesn't mean correct; I am will not get into the ethics questions, because that's an argument not based on facts, but opinions and experience.  And in case my position was unclear, I don't think this was a good situation, I don't think the correct thing was done, but I do feel that is it wrong for the providers to take the fall for the medical director's decisions.

however, quoting the legal issues link that you provided:





> The medical director’s role is to provide medical leadership for EMS. Those who serve as medical directors are charged with ultimate responsibility for the quality of care delivered by EMS, must have the authority to effect changes that positively affect quality, and champion the value of EMS within the remainder of the health care system. The medical director has authority over EMS medical care regardless of providers’ credentials. He or she is responsible for coordinating with other community physicians to ensure that their patients’ issues and needs are understood and adequately addressed by the system.


By that statement, the medical director is responsible for the clinical actions of the paramedics, where the buck stops with him, not with the line staff.  Since this was online direction (and in-person direction), I feel remediation may be appropriate (as well as additional guidance on what to do when you don't agree with the medical director's orders), however having the medical director give you a direct order which you followed should eliminate any disciplinary action for the line staff.


EpiEMS said:


> You don't operate under the license of the medical director - that is a common false assumption. You operate under your state license (or state certification, if they call it that, but it is no different), subject to their supervision.  This is not the same thing. Furthermore, you have the professional and ethical obligation to act in contravention of orders if they are incorrect (after following the appropriate process to ensure you heard correctly).


That is an interesting interpretation, and I do thank you for the link.  It was an interesting read.  It also mentions that EMS personnel are subject to three lines of authority: the medical director, the government agency that regulates EMTs, and their employer.  So whose directions should personnel be required to follow?  Because in this example, they followed 2 out of 3 lines of authority.  


CCCSD said:


> What if the crew transported him after they figured the Doctor was FOS and made bad patient care decisions?


Well, based on the link that @EpiEMS  provided, the crew would have either been terminated or have their ability to practice under that medical director removed, which can have consequences to their employment and licensure.


----------



## CCCSD (Apr 23, 2021)

And since that medical director made a WRONG decision, abandoning the patient, care reverted back to the EMT crew on scene, who should have transported.

MD ego at work.


----------



## Peak (Apr 23, 2021)

Was the medical society that reviewed the doc actually a government body or a peer review, typically the term medical society refers to the latter.


----------



## EpiEMS (Apr 24, 2021)

DrParasite said:


> I think we need to agree to disagree on this one; while I do agree that the appropriate standard of care is national, the AHJ still sets decides what care that they will be applying to their area. otherwise, all ambulances would be staffed identically, with identical protocols, and you could (literally) take a paramedic from a truck in NY and drop him or her on an ambulance in New Mexico, with no issues at all. And we all know that is not the case.


Agreed (and agreed to disagree), AHJ practically speaking sets the standard for a locality, with the caveat that what they do may/may not meet the national standard (whatever that may be in a given circumstance).


DrParasite said:


> By that statement, the medical director is responsible for the clinical actions of the paramedics, where the buck stops with him, not with the line staff. Since this was online direction (and in-person direction), I feel remediation may be appropriate (as well as additional guidance on what to do when you don't agree with the medical director's orders), however having the medical director give you a direct order which you followed should eliminate any disciplinary action for the line staff.


As much as I don't want to ascribe responsibility to the EMS providers, I do think they bear remediating, like you mentioned. I am given to understand that there is precedent in nursing for refusing physician/prescriber orders -- somewhat in line with this scenario, I'll look into this.



DrParasite said:


> That is an interesting interpretation, and I do thank you for the link. It was an interesting read. It also mentions that EMS personnel are subject to three lines of authority: the medical director, the government agency that regulates EMTs, and their employer. So whose directions should personnel be required to follow? Because in this example, they followed 2 out of 3 lines of authority.


I would agree they followed two -- the medical director and the employer. The EMS regulatory body thought they did the wrong thing (perhaps retrospectively) and I do think that you have to hit the center of the venn diagram.



Peak said:


> Was the medical society that reviewed the doc actually a government body or a peer review, typically the term medical society refers to the latter.


I believe the latter -- which is part of the concern for (lack of) objectivity.


----------



## supreme (Apr 25, 2021)

What were the FF/EMTs supposed to do? Transport the patient in the non existent fire ambulance? Transport the patient in the fire truck? Transport the patient on a sheet? Steal EMS’s gurney for transport? The FF/EMTs can’t force anybody to transport, don’t have the proper vehicle to do so, and doesn’t even have a stretcher needed to transport the patient.

My questions are moot if they’re a third service and actually run ambulances. All I can find with a quick google is fire is first on scene and are dual trained as EMTs/not a third service and EMS is privately contracted out.


----------



## ffemt8978 (Apr 25, 2021)

supreme said:


> What were the FF/EMTs supposed to do? Transport the patient in the non existent fire ambulance? Transport the patient in the fire truck? Transport the patient on a sheet? Steal EMS’s gurney for transport? The FF/EMTs can’t force anybody to transport, don’t have the proper vehicle to do so, and doesn’t even have a stretcher needed to transport the patient.
> 
> My questions are moot if they’re a third service and actually run ambulances. All I can find with a quick google is fire is first on scene and are dual trained as EMTs/not a third service and EMS is privately contracted out.


Might want to brush up on your Google-fu.





__





						About Sedgwick County EMS | Sedgwick County, Kansas
					






					www.sedgwickcounty.org
				




They are a county based EMS service, so technically they're government employees.


----------



## supreme (Apr 25, 2021)

ffemt8978 said:


> Might want to brush up on your Google-fu.
> 
> 
> 
> ...





			https://www.kansas.com/news/politics-government/article250294435.html
		


This article says “Wichita Fire Department EMTs”. And “Sedgwick County EMS came back”

Sounds like fire and EMS are two separate entities. If so, I don’t agree with Wichita FF/EMTs being sanctioned per my points above.


----------



## NomadicMedic (Apr 29, 2021)

Here’s today’s follow up.
Mass exodus of EMS workers


----------



## CCCSD (Apr 29, 2021)

So...waaaahhhh...our EMS Director got spanked for being stupid so we all quit?
Fine. Walk. Those spots will be filled quickly.

What a stupid sword to die on.


----------



## GMCmedic (Apr 29, 2021)

CCCSD said:


> So...waaaahhhh...our EMS Director got spanked for being stupid so we all quit?
> Fine. Walk. Those spots will be filled quickly.
> 
> What a stupid sword to die on.


 I read it as they want the director/medical director to leave.


----------



## ffemt8978 (Apr 29, 2021)

GMCmedic said:


> I read it as they want the director/medical director to leave.





CCCSD said:


> So...waaaahhhh...our EMS Director got spanked for being stupid so we all quit?
> Fine. Walk. Those spots will be filled quickly.
> 
> What a stupid sword to die on.


That's the problem with how the story has been reported...we're not given enough info to determine and reading tea leaves hasn't been an accurate method for decades.


----------



## DrParasite (Apr 30, 2021)

CCCSD said:


> So...waaaahhhh...our EMS Director got spanked for being stupid so we all quit?
> Fine. Walk. Those spots will be filled quickly.
> 
> What a stupid sword to die on.


That's actually not what is happening, nor what is being reported.....

the EMS medical director was cleared but the local board (right or wrongly is a different story).... the EMS regulators want him investigated by the MD regulating board, but I haven't heard that it was actually happening.  further, just because you are investigated, doesn't mean you did anything wrong, only that they were looking into it.  The news media is very good at making headline news about an investigation, while the resolution (or finding of nothing inappropriate was found) is buried all the way in the back in small print.  It was the 7 Kansas provider that got spanked not the medical director.

It also seems that the calls to resign are due to the staffing shortage, not because of anything directly related to this particular incident.  and one of the issues is those spots aren't being filled quickly, which is a contributing factor as to why they have 20 spots open.

It seems they have 20 paramedic openings for a county wide system... not a huge number, especially when you divide it up over 4 shifts, and if you have a large system, that can be common.  People quitting EMS jobs isn't really news, it's all too common.  also, this is over the past few years, so likely not a result of this one incident. It would be interesting to read exit interviews and see how their recruitment and retention programs are working.


> "From what I'm hearing there's majors, captains, lieutenants and even just the normal rank and file folks who, if things don't change, they're out the door. That's dozens if not more," said Rep. Blake Carpenter (R) of Derby


The sounds a lot like "anonymous sources" within the agency.  What changes do they want?  what is wrong?  have they tried to get things fixed?  if you are a major or captain, you have the ability to fix some things (hence why you are in leadership positions), so what have you tried? why is an elected representative even involved?  Why didn't they speak to the county commissioner, the county manager, or someone who could actually fix the issue? the county commissioner said "


> Sedgwick County Commission Chair Pete Meitzner says he's open to listen.


these meetings are public, and if things are that bad, why didn't any of the former employees bring them up in the public meetings?  The county EMS agency has an EMS association, so you would think if things were that bad, they would be making all types of noise.

This sounds like an article that makes a lot of assumptions, is very light on actual facts, and is parroting the words of one elected official who may or may not have actually spoken to anyone within the agency.  and the only named person is a former employee, who may have left the agency on not-so-good terms.  So a lot of general statements, and not much actual content that removing the medical director would actually fix.


----------

