Dying patient left on apartment floor

[DrParasite]

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?

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

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]

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]

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).

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.

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.

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]

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]

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.

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.

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.

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]

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]

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]

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).

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.

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.

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]

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]

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]

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.

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]

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

 

[CCCSD]

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]

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]

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

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]

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.