# Nurses Accused Of Negligence In Man's Death



## MMiz (May 16, 2009)

*Nurses Accused Of Negligence In Man's Death*

WOODLAND, Calif. -- State medical reviewers are accusing two local flight nurses of incompetence and gross negligence in the death of a Yolo County bus driver.

On Feb. 25, 2008, Quintin Jones crashed on Highway 16, and within minutes, emergency crews were at the scene.

According to the report, two CALSTAR flight nurses -- who thought Jones was struggling to breathe -- made the decision to perform an emergency cricothyrotomy.

*Read more*


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## VentMedic (May 16, 2009)

Going back a little this got included in Airwaygoddess' adventure.

http://www.emtlife.com/showthread.php?t=7704


It is a sad situation and I want to convey my sympathy to the family and friends of this man. 

The final judgement is not in and until we hear the nurses' side of what happened, it will be difficult to criticize. 

However, it does make one think about the procedures available in their own protocols and how well prepared they are to perform them. Often, advanced procedures such as a cricothyrotomy are not very well covered in Paramedic school and will rarely be mentioned during employment except for referring to the protocols. 

Decisions sometimes must be made in just a few seconds. While what may have seemed to be appropriate at the moment, if it goes bad someone will always be there to hold you responsible for your actions. If it goes well, few will take note except for the patient and his loved ones. But, when being concerned about patient care, that is all who matters.


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## mycrofft (May 16, 2009)

*Cric used to be in basic first aid training decades ago.*

It was covered in the old "EMT-A" training of the first and second editions of the Orange Book. Never had to do one, never knew anyone who personally had to do one except our anatomic exam professor ("Crikey! Thyrotomy!") who advised it was tricky and not frequently of use.

Yes, suspemnd judgement until all sides are herd, but remember that what we do, without that certificate and employment, is assault, battery and worse.


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## DrankTheKoolaid (May 16, 2009)

*re*

This is up in my neck of the woods.  Will be interesting to talk to the other flight crews around here and found out what they have heard from these other nurses.


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## VentMedic (May 16, 2009)

mycrofft said:


> Yes, suspemnd judgement until all sides are herd, but remember that what we do, without that certificate and employment, is assault, battery and worse.


 
Assault and battery?  Without a certificate?   Where did you get this out of that article?  These were licensed RNs on a Flight team.


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## reaper (May 17, 2009)

A cric is the last thing a medic or Rn want to do. If they did it, then there was probably a good reason. We are not getting the whole story here!


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## cprguys (May 17, 2009)

*Two minds think alike*

There were 2 flight nurses and they must have decided that this intervention was the most appropriate.  hindsight is 20/20.  To be the coroner and say that their actions are what caused this gentleman to die, should be saved for an autopsy.  We are given interventions that if not done properly can cause harm or even death, however without them, death could also be the outcome.  I am sure these 2 nurses had this mans best interest at mind.  I cannot wait for the outcome of this case.


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## mycrofft (May 18, 2009)

*To paraphrase my statement*

If an uncertified someone were to walk up to you in the street and do what we do to people professionally, it would be a felony. Parse, please. 

There's no way to "judge" this event.


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## Aussieaid (Sep 26, 2010)

http://lawmedconsultant.com/1236/calstar-flight-nurses-cleared-of-all-charges-in-2008-cricothyroidotomy-incident-video


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## medicRob (Sep 26, 2010)

I might have skimmed over the article too fast, but I don't remember any part of that write up that said the patient had an ET Tube. Now am I correct in assuming that rather than attempting to intubate the patient, that these 2 flight nurses went right for the difficult airway bag and performed a cric?

I don't think it is fair to pass judgement until we hear the RN's side of the story.


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## Aussieaid (Sep 26, 2010)

The full BON report is here: http://rn.ca.gov/public/rn528232.pdf

Interesting reading courtesy of a Flightweb thread on the same.


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## medicRob (Sep 26, 2010)

Aussieaid said:


> The full BON report is here: http://rn.ca.gov/public/rn528232.pdf
> 
> Interesting reading courtesy of a Flightweb thread on the same.



I'll pop on over to my account on flightweb to get some details about the situation.


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## abckidsmom (Sep 26, 2010)

Aussieaid said:


> The full BON report is here: http://rn.ca.gov/public/rn528232.pdf
> 
> Interesting reading courtesy of a Flightweb thread on the same.



Fascinating.  Sounds like it was a nightmare of a call.

I was disappointed to read the judgment on the behavior of the medic that came on the ground ambulance (Emch?).  Her testimony sounded rather hystrionic, and cast her in a negative light to the board.  I felt a little embarassed for all of us to have her play the role of paramedic in this case.  Who stabs from 17 inches away when doing a surgical cric?

I don't know about flight web.  What are they saying over there?


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## Foxbat (Sep 26, 2010)

(deleted)


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## jjesusfreak01 (Sep 26, 2010)

The BON report was interesting. The short version is,

1 An unknown cause led to the driver running off of the road (c/o head pain), and he was ejected from the vehicle
2 During the ejection, he sustained some sort of wound to his neck (possible tracheal transection), either a cut from glass or a tear from hyperextension (This wound was not found during the initial examination by EMS, very strange)
3 He was able to answer the questions of the original responding EMS unit and was ventilated adequately with a BVM
4 During transfer to the flight unit, the medics and nurses turned their back on the patient, at which point he seized the opportunity and went into respiratory failure
5 Multiple attempts at intubation were made by the flight unit, but were unsuccessful (despite placement appearing to be correct, they could not get chest rise)
6 The decision was made to attempt a surgical airway, and by the examiner's report, the incision appeared to be correct, however when a tube was placed air would only travel out the mouth

It appears to me that he had massive bleeding into his lungs from the tracheal transection, which led to his eventual crash when they transferred to the flight nurses, as well as the increasing difficulty they faced in keeping his O2 sat up after each intubation attempt. Because for whatever reason they didn't see the existing laceration, they didn't know he was bleeding into his lungs (although the nurse did notice excess bleeding when they did the cricothyrotomy). The evidence in that report sure makes it look like the surgical airway was justified, but that with his injury it wouldn't have mattered. Also, never turn your back on your patient. This is what 10 seconds of abandonment gets you.


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## sir.shocksalot (Sep 26, 2010)

Interesting read. I think a surgical airway was completely justified in this individual and that there was not much anyone short of a trauma doc in an OR could have done for the pt. Several pathologists found that the pt had sustained an internal tracheal and esophageal laceration when he was ejected that had no outward signs, there was no corresponding skin laceration or anterior tracheal laceration; the internal lacerations were only found on the inside of the trachea and the esophagus, which would have been impossible to see in what sounded to be a disaster of a call.

And the paramedic that testified simply made herself, and the rest of us, sound like an idiot. She claimed that the flight nurses stabbed the pt in the neck and fished around with the scalpel. She also initially stated that she thought the pt's "jugular" had been lacerated during incision, which shows an obvious complete lack of understanding of anatomy and physiology. Furthermore she wasn't trained or authorized to perform a cric anyway.

Good to see that the nurses were found not be be negligent.


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## rhan101277 (Sep 26, 2010)

Paramedic Emch has some strange testimony.  I find it tough to believe a flight nurse would stab the membrane from 16-17 inches away.  That makes no since at all.


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## Aprz (Sep 27, 2010)

It was an interesting read. I think it was just very traumatizing and also had a bad brush off with the flight crew for Emch that she started making up things in her mind. I think everyone does that a little here and there. Like they were saying, her story changed, and I don't think she was purposely lying.


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## akflightmedic (Sep 27, 2010)

Wow...interesting read.

I have a question for people who have regularly handed off to flight crews...if you give report and they take over care, either on scene, in your ambulance, whatever...do you continue to document what they are doing just like the medic did in this case?

If you do, should you? Is it wise to do so, especially when they are functioning at a level above you and it may lead you to document incorrect findings?

Example: When I was on the ground, once the flight team climbed in the truck and received a verbal report and assumed care, that is where my report ended...something along the lines of "At 0130, flight team received verbal report and assumed all patient care."

Was I wrong in doing that? Should I keep documenting? Obviously a caveat may be if they start doing gross misconduct, but routinely should I even mention what they are doing just because I can still see it?


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## Aprz (Sep 27, 2010)

akflightmedic said:


> Wow...interesting read.
> 
> I have a question for people who have regularly handed off to flight crews...if you give report and they take over care, either on scene, in your ambulance, whatever...do you continue to document what they are doing just like the medic did in this case?
> 
> ...


I have no experience in that, but I personally would continue to document. Aren't you still considered assisting? Even if you aren't directly participating with patient care, you are still somewhat involved, and until you are done with anything with the patient period, I'd continue document what I see, but of course if they are doing something beyond your level, I'd be careful of what I say such as "stabbing patient in the neck", haha, like in this case, and if I don't know what's going on, use simple English as usual. That's personally what I would do. Who knows? Maybe that flight crew could turn on you, say you refuse to do anything after you handed the patient off, and that you were being detrimental to patient care. I wouldn't have thought they would do that until reading this article when the paramedic turned on the flight crew. I also heard of it once before, but with an EMT student. I kind of blew him off, but he was talking about how everyone didn't know what they were doing during his ride along like a fire crew didn't hold c-spine on somebody who doesn't need it, they also didn't remove the flaps off non rebreathers, and didn't give everyone non rebreather, and those EMTs and Paramedics should lose their license (our program taught everyone to do it on everyone, taught students to remove the flap incase it malfunctions, but didn't teach everyone to throw a NRB on everyone - that was just him "more doesn't hurt + it's better" :s / obviously I blew him off cause he thought he knew it all and yelled at me saying that you had to remove the flaps off a non rebreather, which I told him you didn't.... Grr... I can't believe he passed the class) At least if you document it, you got something.


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## abckidsmom (Sep 27, 2010)

akflightmedic said:


> Wow...interesting read.
> 
> I have a question for people who have regularly handed off to flight crews...if you give report and they take over care, either on scene, in your ambulance, whatever...do you continue to document what they are doing just like the medic did in this case?
> 
> ...



This is an excellent question, and one I need to put to my agency.  I had always assumed the same as you, "Report given, pt turned over to flight crew, Nurse Smith, for packaging and transport."

When I was a BLS provider and a non-RN ALS provider, I wouldn't have known the names for some of the things they did.  And what a nightmare it would be if I documented one dose of a drug, and they actually gave another.  Or we both documented vital signs, put the same time on our paperwork, and had significantly different information.

I think that answers my question for me.  ONE patient care record.  ONE timeline.  If I feel the need to document, I can do it in an incident report, which seems like it was more what Paramedic Emch was documenting, not a patient care report.


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## akflightmedic (Sep 27, 2010)

I read the link 3 times to make sure I did not misinterpret (and it is still possible) but what I gathered from the medic's report is she did indeed document in her PCR but she also followed up with an incident report...which is what made me bring up the question.

At what point do you stop documenting?

I never really gave it much thought and in all honesty, when I give report, even if they are still on scene, I have officially handed over care and all interventions and vitals from then on out are their responsibility to document. Even if they ask me to hand them something, there is no need for me to make a notation of that.

Now in the event that they ask me to do a procedure, of course I will make note of it, but I currently do not think I need to document any further.

I do recall a discussion about this many years ago in relation to picking up specialty teams from say an airport or LZ and bringing them to a hospital so they could pick up a patient and then transporting them back to the LZ.

For a while, some people would document because we "had a pt" and others would simply note patients name, DOB, DX and say specialty team XYZ with RN... and Medic...on board and handling all patient care needs.

I think this is a similar situation.


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## abckidsmom (Sep 27, 2010)

akflightmedic said:


> I read the link 3 times to make sure I did not misinterpret (and it is still possible) but what I gathered from the medic's report is she did indeed document in her PCR but she also followed up with an incident report...which is what made me bring up the question.
> 
> At what point do you stop documenting?
> 
> ...





I had forgotten about the team runs...yeah, when there's another team responsible for patient care, they get to document the patient care.

Incident reports are a different deal, though.  I have worked with people who wrote incident reports for just about everything, and I've had employers who encouraged that practice.  Maybe that's where the dramatic part of her story came from, the incident report.


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## Aidey (Sep 27, 2010)

I rarely (read once) hand off to flight crews at my current job. However, occasionally we pick up crews with patients and transport them from the airport to the hospital. I'm still required to write a PCR and have two sets of vitals, so yes I end up double documenting. 

To prevent issues when they take vitals, I ask what they were, so we have the same numbers. For my narrative I generally just write who the patient is, where they are coming from, why they are being transferred and then something along the lines of "treatment and assessment done by Acme Air Ambulance crew".


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## akflightmedic (Sep 27, 2010)

After doing what you did a few times....I actually started riding up front with my partner. The team has all equipment needed, a much higher level of education/experience and they have absolutely no need for me to ask or interfere in anything. Therefore, I would simply document pt transported from here to there, no patient care or assessment performed by Medic 5, ALL pt care and assessment performed by ACME R' US.

Yes, it is a good time to learn and ask questions if they are willing to do so, but most times I was just in the way...and quite frankly I had zero interest in neonates which was a lot of the transports I was on.


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## LucidResq (Sep 27, 2010)

Sorry to digress a bit but am I correct in reading that nothing was found on autopsy to suggest any medical cause behind the accident? Any thoughts on why he would veer off the road in such a manner? Did he really just have a severe headache?


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## Aussieaid (Sep 27, 2010)

When you give report and hand off care at a hospital do you continue to document everything the hospital does?  The same applies to turning over care to a Flight crew or anytime you are turning over care to an equal or higher level of care.  Once you have given report and they have _*assumed*_ care you don't need to continue documenting.  You can still assist but now it is whoever has assumed care's responsibility to document accurately.  I have assisted at hospitals to help them out in certain situations but I always leave the documentation up to them as it is their legal responsibility.  I think you are setting yourself up for trouble if you continue to document when it is not your responsibility.  Like someone said though an incident report is a whole other ball game.

On this person there was nothing found on autopsy in his head but that doesn't mean that there was nothing wrong with him.  He could have had severe migraines, meningitis, cerebral vasoconstriction or spasms which can cause TIA's without findings on autopsy (since I doubt this coroner even did any labs.  Seems like he thought he found a cause of death, made assumptions and didn't look any further. :wacko: )


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## Akulahawk (Sep 27, 2010)

When I picked up flight teams, I'd essentially document some very basic stuff about the patient: How transported, how the patient was packaged, any vents/lines/other equipment in place, two sets of vitals (whatever the transport team has) and usually concluded with something along the line of "all patient care provided by and under direction of the (insert transport team)." If I have to go hands-on or perform some delegated task within my scope, (such as providing CPR) that would be documented as "(task) performed by (me) under direction of..." and all that would be before the "all care provided or under direction of..." line.

In any event, from what I read from the final report, it seemed obvious to me that the flight crew did what they thought was best for that patient. The internal injuries could not plausibly come from making a small incision at the midline of the body right at the cricothyroid membrane. I think that this patient had non-survivable injuries.


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## LucidResq (Sep 27, 2010)

Aussieaid said:


> On this person there was nothing found on autopsy in his head but that doesn't mean that there was nothing wrong with him.  He could have had severe migraines, meningitis, cerebral vasoconstriction or spasms which can cause TIA's without findings on autopsy (since I doubt this coroner even did any labs.  Seems like he thought he found a cause of death, made assumptions and didn't look any further. :wacko: )



That's what I'm getting. Maybe there was something else....  I'm not sure if something else was discovered and they didn't find it relevant to this investigation and therefore didn't include it, or if they truly didn't find any underlying cause. 

Kinda sad... I mean what if it's something potentially heritable? If I were this man's family member I would want to know what would cause him to do such a thing in the first place... even if the injury was what actually killed him.


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## Aidey (Sep 27, 2010)

akflightmedic said:


> After doing what you did a few times....I actually started riding up front with my partner. The team has all equipment needed, a much higher level of education/experience and they have absolutely no need for me to ask or interfere in anything. Therefore, I would simply document pt transported from here to there, no patient care or assessment performed by Medic 5, ALL pt care and assessment performed by ACME R' US.
> 
> Yes, it is a good time to learn and ask questions if they are willing to do so, but most times I was just in the way...and quite frankly I had zero interest in neonates which was a lot of the transports I was on.



Company policy is that if there is a patient in the back, one of us has to be in the back. On flight crew transports the EMT can be in the back instead of the Paramedic.


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## Akulahawk (Sep 28, 2010)

Aidey said:


> Company policy is that if there is a patient in the back, one of us has to be in the back. On flight crew transports the EMT can be in the back instead of the Paramedic.


I don't think I've ever worked for a company or agency that didn't have a similar policy. The ambulance crew knows where everything is... the transport team doesn't... it's not their ambulance! I got familiar with several different flight teams from several different agencies and companies. They also got familiar with our equipment, but that didn't mean that I didn't have to be in the back with them. When you know where all the ports, plugs, switches, and other supplies are, things go much more smoothly than if you have to find them without help.


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## akflightmedic (Sep 28, 2010)

First, an ambulance is an ambulance...the majority are very similar in design and I could jump in any unit and be quite comfortable in less than a minute.

However, most specialty teams operate out of THEIR equipment bags. It is their patient, they know their equipment and that is what they use. Realistically, the only two items they ever used of ours was oxygen and suction...occasionally they would dim a light or turn another one on.

If they can not manage that on their own, then there are serious issues. 

Also, most teams have everything needed for the transport taken care of, hooked up, etc prior to them leaving the room the patient is in. They typically need nothing else.

In addition to that, if any emergency occurred, we would stop as they are quite capable of handling it, especially the NICU teams. There would be no turning around, no rushing to get this or that done, they are the experts and they are prepared.

Just sayin...


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## 18G (Sep 28, 2010)

Very interesting read indeed.... it was nice to see such a thorough investigation done. 

One thing I was kinda surprised to see not mentioned was the ruling out of a tension pneumothorax. With the MOI, assessment findings, inability to ventilate and absent breath sounds, a needle decompression wouldn't have hurt.  That was just a thought while reading. 

Sounds like they were very skilled in their performance and had tons of experience. The AMR Paramedic was disgraceful in her testimony.


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## jjesusfreak01 (Sep 29, 2010)

18G said:


> One thing I was kinda surprised to see not mentioned was the ruling out of a tension pneumothorax. With the MOI, assessment findings, inability to ventilate and absent breath sounds, a needle decompression wouldn't have hurt.  That was just a thought while reading.



Although its always possible, there was no thoracic injury they could see that would have caused a pneumothorax and the patient wasn't of the correct bodytype to suspect spontaneous pneumothorax (6ft4in, 280lbs). Honestly, nightmare case all around, I imagine they were all freaking out a little as he slowly went into respiratory failure and they didn't know why. A needle decompression might not have hurt the patient, but remember they are getting chewed out for doing what looks to be a completely justified surgical airway. Of course, I don't advocate for treating based on possible legal liability so long as you are following protocol and sound medical judgement.


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## 18G (Sep 29, 2010)

True, true.... I was just thinking with the very poor compliance, the inability to achieve chest rise, and no audible lung sounds combined with the MOI, a bilateral tension pneumo may have been considered as a possible cause. I think the flight crew knew what was going on and it was just one of those cases that the patient died despite everyone's best efforts.


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