And the jury is back

[akflightmedic]

"If you haven’t ever worked as a Police, please don’t second guess them all."

Which is what the Medics did (or didn't do). They did NOT second guess the police, they took their version of events as fact and then jumped on the wagon. Yes, they screwed up the dose, they did not monitor the guy either for an extended time. But their "call to action" if you will, was to NOT second guess the police.

I strongly feel there is culpability across the board. If you want to RCA this...regardless of the Medics clinical decision-making errors, much of this will trace to the cops, their initial actions and over reactions.

 

[DrParasite]

Which is what the Medics did (or didn't do). They did NOT second guess the police, they took their version of events as fact and then jumped on the wagon.

So EMS providers shouldn't do that? you have a violently resisting person, who is suspected of experiencing excited delirium, who the cops are actively fighting with... should the medics tell the cops to let the person go to see what is occurring? Especially when the person is "in custody of Law enforcement," which might bring up additional questions about how should a person in custody of an officer be treated by EMS?

Yes, they screwed up the dose, they did not monitor the guy either for an extended time. But their "call to action" if you will, was to NOT second guess the police.

So this was a medication error right? Because when I said what the Vanderbilt nurse did was criminal, many people on here disagreed (https://emtlife.com/threads/medication-error-learning.47485/page-3#post-709139 for those who forgot what @Carlos Danger said). In the nurse's case, it was the wrong meds, in this case, it was the wrong dosage, but both medication errors. Wasn't the argument here that medication errors weren't criminal acts, and should be handled in civil court?

I strongly feel there is culpability across the board. If you want to RCA this...regardless of the Medics clinical decision-making errors, much of this will trace to the cops, their initial actions and over reactions.

But who is in jail? who is being held accountable? not the cops (ok, one of the 3 was), but both paramedics were convicted. And I will agree that they should have monitored the patient after the administration, after the scene calms down.

Should they serve time in jail? I don't know, but I don't think prison will "reform" them, so I don't think anyone will benefit from prison, other than the family who want to see "justice served."

All I know is that this furthers my belief that I never want to step foot on an ambulance ever again. the risk is too high for the pay that is too low.

 

[mgr22]

Will any medic or LEO here change the way you do your job because of the outcome of this case?

 

[Carlos Danger]

So this was a medication error right? Because when I said what the Vanderbilt nurse did was criminal, many people on here disagreed (https://emtlife.com/threads/medication-error-learning.47485/page-3#post-709139 for those who forgot what @Carlos Danger said). In the nurse's case, it was the wrong meds, in this case, it was the wrong dosage, but both medication errors. Wasn't the argument here that medication errors weren't criminal acts, and should be handled in civil court?

I don't know that I would call this a medication error per se. Technically, I'm sure it could be classified as such, but the term "error" implies that an unintentional mistake was made in the process of selecting, calculating, and administering the medication. I don't think that is what happened here. The paramedics were quite intentional about the drug, the dose, and the route of administration, and in fact quite a bit of discussion was had about it among several of those on scene before it was given.

As others have said, the bigger issue with the paramedics' actions have more to do with them taking medical direction from cops and apparently failing to adequately assess and monitor their patient. They appeared to be much more concerned with doing what the cops wanted the way the cops wanted it done than with doing what was right for their patient.

 

[Tigger]

So EMS providers shouldn't do that? you have a violently resisting person, who is suspected of experiencing excited delirium, who the cops are actively fighting with... should the medics tell the cops to let the person go to see what is occurring? Especially when the person is "in custody of Law enforcement," which might bring up additional questions about how should a person in custody of an officer be treated by EMS?

So this was a medication error right? Because when I said what the Vanderbilt nurse did was criminal, many people on here disagreed (https://emtlife.com/threads/medication-error-learning.47485/page-3#post-709139 for those who forgot what @Carlos Danger said). In the nurse's case, it was the wrong meds, in this case, it was the wrong dosage, but both medication errors. Wasn't the argument here that medication errors weren't criminal acts, and should be handled in civil court?

But who is in jail? who is being held accountable? not the cops (ok, one of the 3 was), but both paramedics were convicted. And I will agree that they should have monitored the patient after the administration, after the scene calms down.

Should they serve time in jail? I don't know, but I don't think prison will "reform" them, so I don't think anyone will benefit from prison, other than the family who want to see "justice served."

All I know is that this furthers my belief that I never want to step foot on an ambulance ever again. the risk is too high for the pay that is too low.

Much in the same of the Vanderbilt case, it was not the medication administration that led to the catastrophic outcome, but what happened next. Both a moderate overdose of Ketamine and inadvertent use of vec do not have to be fatal if the patient is managed properly. The poor monitoring and treatment to me is the negligence.

For the rest of the discussion:

Do I think they were being lazy with the drug math? Yes. However the proper dose of 350mg and the given dose of 500mg could very well have had the same effect on this patient. I cannot confirm this to be to the case in Aurora, but several other large Colorado EMS systems started with 5mg/kg for sedation, then switched to 500mg flat doses for adults, and then went back to 5mg/kg. You can imagine that when the change back to weight based occurred that lots of people just said “well fine, everyone weighs 100kg.”

As to how I interact with law enforcement, this case and others locally absolutely changed how I interact on these scenes. Firstly if I’m going to sedate, I verbalize a plan that includes making the officers aware that they must get off the patient once sedation is achieved immediately. I’ve had officers straight refuse to get off prone patients who were completely flaccid, one of whom became apneic, aspirated and required airway management . I will never let that happen again. Ideally we aren’t giving meds to patients in a prone position ever. If they are not interested in the EMS plan, we don’t give meds. Most importantly though, we just try to stop and think for a second before grabbing a syringe. These are hot scenes, it’s easy to get rapidly pulled in trying to help. But you have to slow down, figure out what’s going on, decide if sedation is indicated and can be done safely, and then have a plan to rapidly monitor them.

 

[E tank]

Just the availability of field medical intervention at LE request is a flawed idea. No policy, no matter how well written can manage a chaotic scene into something predictable. That these events turn out OK sometimes (as far as anyone knows in the end) is at best lucky. There is no good way to deal with stuff like this, but it's an LE problem, not a medical one until the guy gets to the hospital. Don't know when This became widely available, but however much of a hassle it is to use, that's LE's problem. Unfortunately, it takes events like these for devices like this to get developed. Gets used all the time where I'm at.

 

[CCCSD]

Been using it for years. I’m an Instructor. Guys like it once they become comfortable with it.

 

[CCCSD]

Which is what the Medics did (or didn't do). They did NOT second guess the police, they took their version of events as fact and then jumped on the wagon. Yes, they screwed up the dose, they did not monitor the guy either for an extended time. But their "call to action" if you will, was to NOT second guess the police.

I strongly feel there is culpability across the board. If you want to RCA this...regardless of the Medics clinical decision-making errors, much of this will trace to the cops, their initial actions and over reactions.

I’m speaking of posters on here.

 

[Carlos Danger]

If you haven’t ever worked as a Police, please don’t second guess them all.

Come on, really? This take is only ever used to argue that an individual or group of individuals shouldn't be held accountable for their actions. Sorry, but in this day of body cams and cell phone cameras and Youtube channels where attorneys and former cops break these videos down, you have to do better than that. We are ALL accountable for our actions all of the time, and having the broad legal authority that cops do only makes them MORE accountable, not less.

I would encourage you to read the report issued by the independent review panel (which included a former cop and a former Dept of Justice investigator) sanctioned by the City of Aurora. It is pretty damning of the actions of the police that night. And while you have the option to dismiss it as just a hit piece meant to appease the anti-police crowd, the report breaks down every moment and virtually every word of the interaction and also the follow-up investigations. it is exceedingly detailed and appears very objective.

 

[Tigger]

Just the availability of field medical intervention at LE request is a flawed idea. No policy, no matter how well written can manage a chaotic scene into something predictable. That these events turn out OK sometimes (as far as anyone knows in the end) is at best lucky. There is no good way to deal with stuff like this, but it's an LE problem, not a medical one until the guy gets to the hospital. Don't know when This became widely available, but however much of a hassle it is to use, that's LE's problem. Unfortunately, it takes events like these for devices like this to get developed. Gets used all the time where I'm at.

I’m not sure I agree with making it a law enforcement problem. If there is an underlying medical or toxicological issue, it would seem the individual is now a patient and in need of care. If a provider feels that a patient in custody needs immediate medical intervention, that needs to happen.

Unfortunately aggressively resisting arrest and having a medical issue can look very similar. I have no good answer here. Given the choice I would rather assume care of a potential patient and use chemical sedation rather than have law enforcement transport someone with a potentially serious illness in physical restraints without any monitoring.

 

[E tank]

I’m not sure I agree with making it a law enforcement problem. If there is an underlying medical or toxicological issue, it would seem the individual is now a patient and in need of care. If a provider feels that a patient in custody needs immediate medical intervention, that needs to happen.

Unfortunately aggressively resisting arrest and having a medical issue can look very similar. I have no good answer here. Given the choice I would rather assume care of a potential patient and use chemical sedation rather than have law enforcement transport someone with a potentially serious illness in physical restraints without any monitoring.

I'll refine my statement...it's not a sedation problem.....until the guy gets to the hospital.

 

[Tigger]

I'll refine my statement...it's not a sedation problem.....until the guy gets to the hospital.

I guess I don’t get it. No medical care should provided until arrival at the hospital?

 

[E tank]

I guess I don’t get it. No medical care should provided until arrival at the hospital?

Sometimes thoughtful medical care consists of prudentially doing nothing. In a high intervention rate culture, that may seem counter intuitive but just transporting the patient to definitive care without anything else is providing medical care.

 

[Tigger]

We’ll agree to disagree I suppose. Working with the police with agitated patients is a not insignificant part of EMS call volume these days.

 

[DrParasite]

I would encourage you to read the report issued by the independent review panel (which included a former cop and a former Dept of Justice investigator) sanctioned by the City of Aurora. It is pretty damning of the actions of the police that night. And while you have the option to dismiss it as just a hit piece meant to appease the anti-police crowd, the report breaks down every moment and virtually every word of the interaction and also the follow-up investigations. it is exceedingly detailed and appears very objective.

I read the report... and have questions...
1) Why was EMS called? it looks like someone was resisting arrest... does APD always call for EMS when someone is resisting arrest?
2) They didn't give ketamine until the ambulance got there. before the ambulance arrived, it seemed like the victim was still resisting arrest (a LE matter), and the APD was working on restraining him. If you have a person who is resisting arrest, should EMS be attempting to assess the patient, or is that an unsafe scene? should they have put the arrestee on a monitor (does AFD carry them? idk if they need to wait for the ambulance before they get any ALS equipment)

he poor monitoring and treatment to me is the negligence.

For the rest of the discussion:

Do I think they were being lazy with the drug math? Yes. However the proper dose of 350mg and the given dose of 500mg could very well have had the same effect on this patient. I cannot confirm this to be to the case in Aurora, but several other large Colorado EMS systems started with 5mg/kg for sedation, then switched to 500mg flat doses for adults, and then went back to 5mg/kg. You can imagine that when the change back to weight based occurred that lots of people just said “well fine, everyone weighs 100kg.”

3) yes, the fire medic was lazy with drug math, and he overestimated his weight. It's nighttime, a large jacket, and the victim was fighting off 4 cops... I can understand why he erred on the high number.
4) why was he kept in a prone position on the grass by PD? even if cuffed, this sounds like a recipe for disaster... and this was before the ketamine was administered. and he wasn't fighting for about a minute before the Ketamine was administered... so, why? Going back to question #1, he was resisting arrest; should chemical restraints be requested for every person who is fighting a (lawful) detainment?

As to how I interact with law enforcement, this case and others locally absolutely changed how I interact on these scenes. Firstly if I’m going to sedate, I verbalize a plan that includes making the officers aware that they must get off the patient once sedation is achieved immediately. I’ve had officers straight refuse to get off prone patients who were completely flaccid, one of whom became apneic, aspirated and required airway management . I will never let that happen again.

So what are you going to do? are you going to forcibly remove the officer from the patient? I am not disagreeing that the officer needs to get off the patient before the patient dies, but EMS isn't an authority to order the cop to do that. And you can ask for a PD supervisor, to respond, but that's going to be a couple minutes till they arrive. If the person is in police custody, aren't they responsible for what happens to them? Not only that, but these types of situations WILL occur and should be discussed by white shirts over coffee in the office, not at a scene at o dark 30.

These are hot scenes, it’s easy to get rapidly pulled in trying to help. But you have to slow down, figure out what’s going on, decide if sedation is indicated and can be done safely, and then have a plan to rapidly monitor

I think that's actually a great point, one we (the EMS community) are overlooking: these are active scenes, and they are unpredictable. Reading the report, what should the paramedics have done? Assuming the Ketamine was a good faith administration, how much time went by from the time the medication was administered until he was in the back of the ambulance? should the patient have immediately been placed on a heart monitor with ETCO2? does AFD carry lifepaks on the engine? or can that wait until the ambulance? Has anyone else ever delayed putting a patient on the monitor, and waited until they were in the back of the ambulance? Too much Ketamine is not a good thing, but if they had ventilated him immediately, would the outcome have been better? how about this question: should they have worked the cardiac arrest on scene, vs transporting with CPR in progress?

One thing I was told when I moved to NC was that chemical restraints are always preferred over physical restraints; in NJ, it was typically the opposite. However, administration should be at the discretion of the paramedic who will be administering it, not based on anyone else's request.

 

[Tigger]

Every place I have ever worked in Colorado law enforcement would call for EMS anytime there was a use of force. It has not been uncommon to go for what the cops call a med clear and find them still fighting with people although seems to be decreasing lately. Law enforcement was also “educated” to call for medical in cases of presumed “excited delirium” or “superhuman strength.” No idea if this is common in the rest of the country but I’m not surprised to hear that these paramedics ended up in that scene.

I don’t know what I would do if a cop refused to get off someone I’ve sedated. Since we started laying out plans with them prior to any sedation things have gone smoothly.

 

[Phillyrube]

Good thread, good responses, good interactions. EMS professional. 40 years Fire/ EMS, 23 as a cop and supervisor.