# Mass. health department recommends 2 EMTs be suspended



## VentMedic (Jun 3, 2009)

And yet another news story where EMS has failed to correctly pronounce death. If you believe the baby is no longer alive, at least confirm death or go through the motions while offering support to family. Don't just stand there and at least try to write an accurate patient care report. 

http://www.turnto10.com/jar/news/lo...artment_recommends_2_emts_be_suspended/14145/


*Mass. health department recommends 2 EMTs be suspended*



> Investigators from the Department of Public Health said Brody told them that *he thought the baby was already dead.*
> 
> “I don’t believe that they made a decision thinking that in any way that they were affecting the chances of the young child to live,“ Lang said.
> 
> ...


----------



## boingo (Jun 3, 2009)

There is nothing really indicating this child wasn't in fact, dead.  Was CPR indicated?  Don't know, perhaps the child was non-viable, despite the cop or families wishes.


----------



## emtfarva (Jun 3, 2009)

*more about the case.*

http://www.southcoasttoday.com/apps/pbcs.dll/article?AID=/20090602/NEWS/906020336

http://www.southcoasttoday.com/apps/pbcs.dll/article?AID=/20090603/NEWS/906030333

I don't know the details other than what was reported. Were they wrong?


----------



## Meursault (Jun 3, 2009)

boingo said:


> Was CPR indicated?


The sup certainly thought so, and as far as I know, they didn't determine death or indicate that they were calling the code. We might find out more, but those Standard-Times articles indicated at least one of them had some incidents in the past.


----------



## emtfarva (Jun 3, 2009)

well did they think it was sids? i haven't heard about this till today. I wish the ME's report would come back, it has been like 6 months.


----------



## boingo (Jun 4, 2009)

Interesting.  The supervisor, pending lay off reports the deficiency in medical care to the Mayor?  It seems to me the medical director and training staff should have been the ones notified, and remedial training in PALS etc...as well as an incident report from the crew explaining their actions, or lack thereof.  This stinks like sour grapes, perhaps with a grain of truth.  Not too sure if dicipline or education is the answer.


----------



## VentMedic (Jun 4, 2009)

The MA statute on Cessation of Resuscitation (Appendix C) is very vague as to how it applies to children. If the Paramedics were certain the baby was deceased they could have just contacted their medical control and then supported the family.

http://www.mass.gov/Eeohhs2/docs/dph/emergency_services/treatment_protocols_appendix_704.pdf


----------



## VentMedic (Jun 4, 2009)

Looks like these two Paramedics are getting off easy especially with their track record for making good clinical judgments. 

http://www.southcoasttoday.com/apps/pbcs.dll/article?AID=/20090602/NEWS/906020336


> During the course of investigating the December incident, the state discovered two additional incidents — one involving Nunes and one involving Brody — that raised concerns about patient care.
> 
> The first occurred on Nov. 19, when Nunes responded to a 911 report about a family of four suffering possible carbon monoxide poisoning; Nunes was accompanied on the call by an emergency medical technician-intermediate — a lower level of certification than a paramedic.
> 
> According to the report, Nunes canceled a second ambulance that was on its way and transported all four patients to St. Luke's in an ambulance designed to accommodate no more than two patients. Additionally, the patients were not given oxygen before or during the trip to the hospital, the report stated.


 
*I will emphasize again, these news posts should be used as a teaching tool to see how your own P&Ps would apply in these situations and what you should be doing so you do not make the same mistakes to give the forums something to talk about. *


----------



## boingo (Jun 4, 2009)

There track record is a bit concerning, I'm curious how they came to light.  I mean, I have transported 4 pts w/minor complaints at one time to make the most use of limited resources, I'd be surprised that someone would have filed a complaint with the state about that, certainly if the one complaining was a co-worker.  As for the lack of O2, we do a lot of calls for ? CO only to turn out the family has a shared illness and no CO condition exists.  Doesn't seem like major red flag type stuff.  I do agree that if there were any question as to the viability of the kid at the very least med control should have been consulted.  I would imagine that with a baby your instinct to work it would be quite high, I know I've worked kids that in retrospect, had they been an adult would have been called on the spot.  I'd love to hear the whole story, what the kid looked like in the ED, etc...


----------



## VentMedic (Jun 4, 2009)

boingo said:


> I mean, I have transported 4 pts w/minor complaints at one time to make the most use of limited resources, I'd be surprised that someone would have filed a complaint with the state about that, certainly if the one complaining was a co-worker.


 
It may depend on how it got billed.  Transporting several patients at a time gets a different fee schedule.  If not, the company can be charged with fraud and face very stiff penalties from the various insuring agencies.  Thus, those who do the billing must know this and it may be something they must report to those in charge.  



boingo said:


> As for the lack of O2, we do a lot of calls for ? CO only to turn out the family has a shared illness and no CO condition exists.


 
The call goes out for questionable CO exposure to a whole family. They called an ambulance probably because they weren't feeling too well.  Are you going to withhold O2 because they look all "pink" and maybe if you have a pulse ox, it says 100%?  Do you have a reliable means to test for CO at scene?


----------



## CAOX3 (Jun 4, 2009)

Yes I would have to agree the to previous incidents are weak at best.  Especially the near syncope.  

Sounds like their reaching, as far as the CPR on the child.  There has to be more to the story, nobody just witholds CPR from a viable child, at least I hope not.


----------



## boingo (Jun 4, 2009)

Yes I can check for CO, and I can monitor SpCO too.  I wouldn't withold O2, however I would wager the family of 4 walked to the truck with minor illness complaints, w/o a detectable CO level.  Its an urban EMS taxi ride.   I could be wrong, just playing devil's advocate.


----------



## VentMedic (Jun 4, 2009)

boingo said:


> Yes I can check for CO, and I can monitor SpCO too. I wouldn't withold O2, however I would wager the family of 4 walked to the truck with minor illness complaints, w/o a detectable CO level. Its an urban EMS taxi ride. I could be wrong, just playing devil's advocate.


 
Of course every call is just BS if it doesn't have blood and guts pouring out while a family of 4 has nothing better to do than take a cool ambulance ride.  I bet they even got the L&S for their enjoyment.

We still check the Masimo reading with a CO-OX measurement to see if HBO is required.  As with any non-invasive monitoring, there is an acceptable margin of error.

Do you know what strain even minor CO levels can do to some people. Children just exposed to second hand cigarette smoke can have their CO level raised to a point where it can produce abnormal cardiac and O2 consumption as well as all the other pulmonary conditions.  Thus, this is the reason why some states no longer allow smoking in a car with children present.

This is one I would rather error on the side of caution. The same for an episode of syncope with a child.  Children don't typically just faint.


----------



## CAOX3 (Jun 5, 2009)

I would er on the side of caution, I wouldnt deplete resources in this case four ambulances or place them on O2 unless they were symptomatic or fire reported high CO readings.  By the way people panic when they hear low battery warningS on CO detectors this also has to be taken into account.

As far as the kid with the near syncopal not being on O2.  I am assuming they are able to conduct a simple assessment to determine if the child NEEDS O2. I dont know how many times we have been dispatched to a kid not breathing,  show up and the kids picking his nose and eating it.  Parents panic they are not usually reliable sources of information especially first time parents.

I will give them the benefit of the doubt.   if these are the only examples they ve come up with to muddy the waters in an attempt to prove their sub par providers there isnt much of a case.

If they did indeed withold CPR, then they should be dealt with accordingly.


----------



## VentMedic (Jun 5, 2009)

We could debate this forever, however, if you do not document why or why not you did not do something, it will bite you in the arse regardless of how BS you think the patients are. If you think your patient is just a BS call, it is your responsibility to document an assessment that justifies your assumption whether it is some BS sprained ankle or a child that appears to be dead that you may also believe to be BS.

Some need to stop making excuses to justify mistakes what could easily have been prevented by just doing a decent assessment with good documentation. If there had been adequate documentation in any of these accusations, there probably would not be a permanent mark on their personnel records by either the company or the state.

It doesn't matter how much you perceive these incidents to be minor BS, it may show a pattern of poor assessment, poor judgment and poor documentation. 

Sometimes when one perceives their calls to be just BS, they get sloppy with their assessments and documentation.


----------



## CAOX3 (Jun 5, 2009)

Just stating there are always two sides to a story.

I read the article again the only question I have is if your transporting the patient they must be viable, right?  Im not going to transport anyone thats not viable even if it is a child.  If this is the case why isnt CPR being initiated or continued?


----------



## VentMedic (Jun 5, 2009)

If the documentation for starting or stopping CPR is not there, then how can you present a case for the child not being viable? 

Are you going to court and just say, "yeah the kid looked dead so we didn't do CPR"? The documentation is what is in question. It is difficult to say what was going through the Paramedics' minds if they did not document adequately.

We've already been through the to transport or not to transport the dead. However, if you don't adequately assess and document the baby is dead, you do not have a chance when the state and the attorneys question you.


----------



## CAOX3 (Jun 5, 2009)

Your missing my point, In the article posted from south coast it states the child was taking to the ambulance and when the supervisor arrived there was nothing being done.  

My question is if they determined the child was not viable or in their words "dead" why was the child moved to the ambulance for transport? If he was in fact not viable he should have never been moved, the child should have been left there and med control/medical examiner called.


----------



## VentMedic (Jun 5, 2009)

I posted the link to MA's Cessation of Resuscitation in an earlier post.   There is no clear statement about kids in it.   They use the terms 18 or older when discussing when to declare death.

I personally would have done an assessment and contacted medical control for any further verification orders since this was a child and MA's statute is slightly vague.  Then, if the child is determined to be dead by my assessment with an MD's final say, I would have turned my attention to the parents.


----------



## boingo (Jun 5, 2009)

VentMedic said:


> Of course every call is just BS if it doesn't have blood and guts pouring out while a family of 4 has nothing better to do than take a cool ambulance ride.  I bet they even got the L&S for their enjoyment.
> 
> We still check the Masimo reading with a CO-OX measurement to see if HBO is required.  As with any non-invasive monitoring, there is an acceptable margin of error.
> 
> ...



No one said it was BS, I'm just not convinced it was a transport of 4 critically ill patients.  You worked EMS in a poor, urban area yourself, how many of these calls have you done?  Thousands probably.  All deserve a thorough hx and exam, however at the end of all that, sometimes minor illness is just that, minor.  A ride to the hospital, a seat out at triage, and an eventual work up will be done.  You are the expert on oxygen therapy here, and I'm sure you don't subscribe to the theory that everyone needs high flow o2.  What makes these patient any different, other than a cook book that suggests everyone should get it?  Either there is room for critical thinking or not.  I have no idea how those complaint got filed, was it the disgruntled supervisor, problem w/nursing staff, or someone else.  What was done for those patients at the hospital?  Were they tx with o2?  What were the results of any tests run?  I don't think we can crucify these two based on what we have seen here, although I guess it can be a good lesson in why we need to write a thorough chart.


----------



## boingo (Jun 5, 2009)

CAOX3 said:


> Your missing my point, In the article posted from south coast it states the child was taking to the ambulance and when the supervisor arrived there was nothing being done.
> 
> My question is if they determined the child was not viable or in their words "dead" why was the child moved to the ambulance for transport? If he was in fact not viable he should have never been moved, the child should have been left there and med control/medical examiner called.



Again, speculation on my part, but I have been to many a call like this were a FF or cop comes flying out of the house with the dead kid in his arms, not much you can do at that point but load it in the truck.  I have called kids like that, notified the hospital and not attempt to resuscitate.  It may have been the plan until the supervisor showed up and decided to work it.  I would love to see their chart, I can only assume it was poorly written, otherwise this wouldn't be news.  For these medics not to work the kid I'd like to believe this was obviously non-viable, however I don't know the facts.


----------



## VentMedic (Jun 5, 2009)

boingo said:


> No one said it was BS, I'm just not convinced it was a transport of 4 critically ill patients. You worked EMS in a poor, urban area yourself, how many of these calls have you done? Thousands probably. All deserve a thorough hx and exam, however at the end of all that, sometimes minor illness is just that, minor. A ride to the hospital, a seat out at triage, and an eventual work up will be done. You are the expert on oxygen therapy here, and I'm sure you don't subscribe to the theory that everyone needs *high flow o2*. What makes these patient any different, other than a cook book that suggests everyone should get it? Either there is room for critical thinking or not. I have no idea how those complaint got filed, was it the disgruntled supervisor, problem w/nursing staff, or someone else. What was done for those patients at the hospital? Were they tx with o2? What were the results of any tests run? I don't think we can crucify these two based on what we have seen here, although I guess it can be a good lesson in why we need to write a thorough chart.


 
At what percentage, adult or *child*, does your facility dive the patient? How many clock hours for the half life does your facilty treat with O2? What was the PPM and length of exposure? See charts below which are from any standard medical manual for CO poisoning.

Your definition of critical is different than mine. If a patient has the proper treatment initiated for CO poisoning, they may not need an ICU. 

I could also go into my lecture about what "high flow" O2 is and the difference between "high flow" and "high FiO2" but I have already done that many times on this forum. It is a shame too few get this basic education about O2 therapy in school to not know the capabilities of their O2 devices.

There are 5 things that we are very aggressive with O2:
1. CO poisoning
2. Sepsis with lactate > 4 mmol/L
3. PPHN of the newborn
4. DCS
5. ARDS until the treatment with adequate PEEP, pressors, buffering and monitoring are in place. Pulmonary HTN may also run on this protocol until NO or one of the other pulmonary vasodilators is in place. 

There is one thing we will try to hold off with aggressive O2 therapy, at least until the Prostaglandin is started, and that is ductal dependant cyanotic heart disease. We may even go to 16% O2 for them.

Many times EMS does not realize how sick the patients they transport actually are. The same for those that do IFT on the elderly patient with a fever. This is not just me talking as there have also be studies to show that. Lab values and other diagnostics are not available in the field nor is the education about various disease processes. 

Back to MA, some agencies want their Paramedics to follow their protocols. Your protocols may not be the same as theirs and they may have missed a few steps to determine death which may include contacting a physician for a child. So, you are judging just from your own recipe book. 

Its not like we haven't heard of a Paramedic failing to see if a patient is really dead lately.

*Symptoms Associated with a Given Concentration of COHb*
*COHb **Symptoms and Medical Consequences*
*10%* No symptoms. Heavy smokers can have as much as 9% COHb.

*15%* Mild headache.

*25%* Nausea and serious headache. Fairly quick recovery after treatment with oxygen and/or fresh air.

*30%* Symptoms intensify. *Potential for long term effects especially in the case of infants, children, the elderly, victims of heart disease and pregnant women.*

*45%* Unconsciousness

*50+%* Death

*Symptoms Associated with a Given Concentration of CO Over Time*
*PPM CO **Time **Symptoms*
*35* 8 hours Maximum exposure allowed by OSHA in the workplace over an eight hour period.

*200* 2-3 hours Mild headache, fatigue, nausea and dizziness.

*400* 1-2 hoursSerious headache-other symptoms intensify. Life threatening after 3 hours.

*800* 45 minutes Dizziness, nausea and convulsions. Unconscious within 2 hours. Death within 2-3 hours.

*1600* 20 minutesHeadache, dizziness and nausea. Death within 1 hour. 

*3200* 5-10 minutesHeadache, dizziness and nausea. Death within 1 hour. 

*6400* 1-2 minutesHeadache, dizziness and nausea. Death within 25-30 minutes. 

*12,800* 1-3 minutesDeath


----------



## boingo (Jun 5, 2009)

I'm not judging at all, I'm argueing there could be a rational reason for witholding CPR, perhaps the documentation of those reasons are in question. The fact that a recently layed-off supervisor blows the whistle in 2 letters to the Mayor, as opposed to the physician medical director makes me question the validity of his claims, despite the fact that the DPH seems to agree.  Poor documentation is likely, however this is likely a poor attempt at justifying the supervisors job.  I would love to hear the medical directors take on all of this, I know if it were me, my medical director would be directly involved as I assume would yours.  Perhaps they are guilty as charged, time will tell.  But until we have access to the chart, the ED chart and the post, I think I'll leave my torch and pitchfork at home.


----------



## emtfarva (Jun 6, 2009)

there might be another side to this story that no one has heard. both of the medics are union leaders. the supervisior was not.


----------



## SauceyEMT (Jun 6, 2009)

boingo said:


> The fact that a recently layed-off supervisor blows the whistle in 2 letters to the Mayor, as opposed to the physician medical director makes me question the validity of his claims, despite the fact that the DPH seems to agree.



It seems, to me anyway, that the physician medical director probably only had the run sheet/report to go on, thus not reporting anything. The report says they continued CPR and transported. The problem comes in when the on-scene supervisor is contradicting the run sheet by saying that he saw that CPR was NOT being performed as indicated on the run sheet. Now there are questions as to the ACTUAL care that was given, thus the investigation.


----------



## emtfarva (Jun 6, 2009)

one more thing is that the mayor didn't know about the case until OEMS pulbished their report. and the whistle blower brought it to the attention of OEMS.


----------



## Hal9000 (Jun 7, 2009)

I wonder if there were enough seat restraints on the ambulance for four patients and two medical providers.


----------



## vquintessence (Jun 7, 2009)

Hal9000 said:


> I wonder if there were enough seat restraints on the ambulance for four patients and two medical providers.


Yep.

At least two pair of seatbelts on the bench seat (typically three pairs).  Then there's the tech seat, and then the stretcher.  That's four or five right there alone.  Then there could also be a CPR seat.  Then the two seats in the cabin up front.  

You haven't the pleasure of a clown car experience yet?  Not a lot of Italians in your area?  jk, jk


----------



## Hal9000 (Jun 7, 2009)

Good to know.  I'm not familiar with ambulances in that area.  I've worked on Type I, II, and IIIs and I have seen some services put way too many people in IIs.


----------

