how to fix EMS

[JJR512]

That covers negligence, but what about malpractice? As to the second part of your question about doctors commenting on out of hospital treatment, they do it now. An expert witness is somebody with education and credentials after their name, not a random lay person picked off the street (that's reserved for juries).

My personal feeling is that we need tort reform before we can really reform EMS in any meaningful manner.

You may be right about tort reform, but as for expert witnesses, I wasn't proposing that a random lay person be used. I was proposing that only a prehospital EMS provider can truly say what a prehospital EMS provider would have done in a particular set of circumstances.

As for "what about malpractice", malpractice is just a specific term for the type of negligence being discussed in these last few posts. That is, malpractice is a type of negligence in which a professional had a duty to act, failed to act according to the accepted professional standards, and damages were caused as a result.

 

[ffemt8978]

You may be right about tort reform, but as for expert witnesses, I wasn't proposing that a random lay person be used. I was proposing that only a prehospital EMS provider can truly say what a prehospital EMS provider would have done in a particular set of circumstances.

As for "what about malpractice", malpractice is just a specific term for the type of negligence being discussed in these last few posts. That is, malpractice is a type of negligence in which a professional had a duty to act, failed to act according to the accepted professional standards, and damages were caused as a result.

I understand, but was pointing out that the opposing attorney is going to stack the deck in the best way possible for their client. If they think a doctor on the stand will be more credible to the jury, then that is what they are going to use. It's going to be real hard for the defense attorney to convince a jury that the doctor is wrong and they should believe the defense's expert (an EMS provider) instead. Right or wrong, that's the way the system works...the most credible witness is the one the jury believes.

 

[JPINFV]

Malpractice attorneys would probably love this type of scenario. Think we live in litigious society now, just imagine how bad it would be if we didn't have medical control and protocols to use in our defense. The only further education that would actually help would be a MD, since that is the expert witness the opposing attorney will present at trial to show that an EMS providers "judgement" caused harm to a patient.

Who said that there won't be expert witnesses on the defense's side if the defense's treatment plan is supportable?

Just curious, how many people here have first hand knowledge of an EMT who was successfully sued while providing non-negligent care*? I'm willing to bet that the actual risk of being involved in a lawsuit for an EMT or paramedic is relatively low and I think has very little to do with a Befehl ist Befehl (orders are orders) defense.

*In other words, I don't want to hear about the idiot crew who were successfully sued for crashing an ambulance while transporting with lights and sirens.

 

[JPINFV]

Can a doctor say, as an expert witness, what a reasonably prudent prehospital EMS provider should have done? Can a person with very advanced training and education, and access to a wide variety of tests, treatments, and all the other benefits of practicing in a hospital put all of that out of his or her mind to say what a person of lesser education, with only a handful of test and treatment options available, should have done?

Yes. A physician can say what medical care would be appropriate given the information at hand. Surprisingly enough, physicians don't just randomly order tests. Surprisingly enough, treatment may be begun before tests are arrived. Surprisingly, in plenty of cases, the standard of care is to treat either empirically (it doesn't matter what bug you're infected with, the antibiotic covers all in that class) or clinically (99% of the time a patient presents this way, this is the cause. The other 1% isn't life threatening. Here's your prescription, call us back in a week if it isn't working).

 

[ffemt8978]

Who said that there won't be expert witnesses on the defense's side if the defense's treatment plan is supportable?

Just curious, how many people here have first hand knowledge of an EMT who was successfully sued while providing non-negligent care*? I'm willing to bet that the actual risk of being involved in a lawsuit for an EMT or paramedic is relatively low and I think has very little to do with a Befehl ist Befehl (orders are orders) defense.

*In other words, I don't want to hear about the idiot crew who were successfully sued for crashing an ambulance while transporting with lights and sirens.

http://www.washingtondcinjurylawyerblog.com/2011/03/familys_washington_dc_wrongful.html

http://www.washingtondcinjurylawyerblog.com/2010/10/washington_dc_wrongful_death_p_1.html

http://www.northcarolinainjurylawyerblog.com/2010/02/deceased_chapel_hill_high_scho_1.html

http://www.weitzlux.com/medicalmalpractice/OhioEMS_1934997.html


That's just from the first page of a quick Google search. You can draw your own inference as to why they are all from law firms. I'm sure the providers didn't feel like they were providing non-negligent care, but it is obvious somebody does.

 

[JPINFV]

Paramedics refused care (the pulmonary embolism called GERD)
Paramedics refused care
Paramedics refused care (the paramedics who refused to transport a high school football player who was complaining about severe cramps and abdominal pain following practice).
Might be an actual malpractice case.

Links go to EMTLife discussion threads on those specific cases...

However, I didn't ask for a Google search, I asked about how many of your coworkers that have been sued. Additionally, all of those articles said that the lawsuit was filed, not that a judgment was rendered (albeit, I'm pretty sure that at least two of those are going to be rendered for the plaintiff).


I can Google search and find physicians being hit with medical malpractice suites. There are bad apples in every profession, and Befehl ist Befehl isn't going to protect them anyways.

Also, med mal suits are expensive. Lawyers don't like to make bad investments. So the "OMG, I have to make a decision and I'm going to get sued for it" unless the decision is basically manifestly wrong anyways (because, you know, you're going to suggest that the chest pain patient has GERD, right?), there's a low risk of being hit with a suit.

 

[JJR512]

Yes. A physician can say what medical care would be appropriate given the information at hand. Surprisingly enough, physicians don't just randomly order tests. Surprisingly enough, treatment may be begun before tests are arrived. Surprisingly, in plenty of cases, the standard of care is to treat either empirically (it doesn't matter what bug you're infected with, the antibiotic covers all in that class) or clinically (99% of the time a patient presents this way, this is the cause. The other 1% isn't life threatening. Here's your prescription, call us back in a week if it isn't working).

None of your "surprisingly enough" is any surprise to me. You don't need to speak to me like I'm a dumbass idiot.

Doctors can do all that because they have more training and education that enables them to do all that. What may be obvious to a doctor might not not be so obvious to a prehospital EMS provider, even one with an AAS. A doctor could think it should have been obvious what was wrong with the patient, and since the EMS provider didn't recognize it he's obviously incompetently negligent. And this is what he will say in court as an expert witness. This is why doctors should not be able to say what a prehospital EMS provider should have done. One cannot simply put a vast amount of knowledge and training out of one's mind and say what one with only a small fraction of that would have done. One can put it out of one's conscious mind, but it's still there in one's brain, and whether one realizes it or not it, it affects the way one thinks and reasons.

Perhaps this should be one of those tort reforms that ffemt8978 mentioned. Making sure that the standard of care is testified to on an expert basis only by someone of equal level and training as the accused.

 

[JPINFV]

None of your "surprisingly enough" is any surprise to me. You don't need to speak to me like I'm a dumbass idiot.

Saying that physicians don't know how to provide care minus the fancy tests and under stress (the underlying meaning of the line about "access to a wide variety of tests, treatments, and all the other benefits of practicing in a hospital") is like a physician calling paramedics "ambulance drivers" with the intent of honestly meaning that all they do is drive ambulances. So, yes, I'm a little bit sensitive to lines that discuss or imply that "physicians just don't understand EMS because they have access to an x-ray."

Doctors can do all that because they have more training and education that enables them to do all that. What may be obvious to a doctor might not not be so obvious to a prehospital EMS provider, even one with an AAS. A doctor could think it should have been obvious what was wrong with the patient, and since the EMS provider didn't recognize it he's obviously incompetently negligent.

While I agree that physicians can catch things easier because of our education/training, that doesn't mean that we expect everyone to pick up everything, especially the zebras. However, there's a huge difference between not picking up a final diagnosis and not picking up either what should be blatantly obvious, or patients who need to go to the hospital for a further workup. If paramedics are constantly electing to not transport patients who should get a further workup (let me point to Mr. Chest Pain case or Mr. HS athlete case above) or missing the blatantly obvious life threatening emergencies (otherwise known as their job), then I have to question if it's worth it to defend them under the status quo. Yes, I have faith that most physicians expect, at most, that paramedics and EMTs are supposed to be capable at their given the educational and diagnostic limitations and can differentiate what is reasonable. Not considering a pulmonary embolism as a potential cause of chest pain should not be an unreasonable expectation of a paramedic.

And this is what he will say in court as an expert witness. This is why doctors should not be able to say what a prehospital EMS provider should have done. One cannot simply put a vast amount of knowledge and training out of one's mind and say what one with only a small fraction of that would have done. One can put it out of one's conscious mind, but it's still there in one's brain, and whether one realizes it or not it, it affects the way one thinks and reasons.

Who should then? Would you rather have your care judged by someone who barely passed high school who seriously believes in protocols as cookbooks?

Alternatively, if one can reason that, while obvious to a physician, may not be obvious to a paramedic, why would he or she be unable to articulate that in a court of law? Just about all of the malpractice cases I've heard about are either acts of gross stupidity or failures in technique. I can't recall any time that I've seen a suit for, say, misdiagnosing a pericarditis as an MI. Similarly, yes. I think a physician could validly say that a paramedic should be able to catch an esophageal intubation, regardless of the technology available. After all, it's infinitely more likely to be sued for not correcting an esophageal intubation than intubating (but catching and correcting) an esophageal intubation.

Perhaps this should be one of those tort reforms that ffemt8978 mentioned. Making sure that the standard of care is testified to on an expert basis only by someone of equal level and training as the accused.

The problem is that then we have the stupidity of "everyone with a trauma get's a backboard" or "everyone gets oxygen" because that's the classroom "standard of care."

 

[MrBrown]

We have been leaving people at home for years, and yes some of them die.

It is however, not reasonably practical to transport every single person who calls for an ambulance now is it?

 

[DrParasite]

best way to fix EMS? scrap the entire system, and replace every ambulance with a doctor (to act as brains), a nurse (to do the clinical work), and an EMT (to drive and and act as muscle, but do very little actual patient care).

this way you get the best of both worlds, and you can scrap system that we have and replace it with one that is better for the patient.

 

[MrBrown]

Brown does not think that physician based ambulances are the answer.

Significant Medicaid/Medicare reimbursement and taxation reform is in there somewhere however as is overhauled education and professional standards.

Why is there no incentive to move anywhere? Because your service has no money, your medical director does not trust you and nobody wants to pay taxes to support any of it and the system is so broken and fragmented nobody knows what anybody else is doing.

 

[the_negro_puppy]

We do not have to worry about law suits as much as we are not a crazy litigious society (yet). We are immune from personal liability in the practice of our job, however our Ambulance service can be sued.


I might also add, while we do not have medical control, we are required and can consult for certain things. For example we cannot give fluids to paediatrics without a consult. However if we had in ICP with us, they would be able to give without consult.

We dont even have to notify hospitals that we are coming. The only time we call hospitals is if we have a critical patient/STEMI/Trauma or need to clarify if the hospital is suitable for a certain condition/illness/injury

 

[MrBrown]

We do not have to worry about law suits as much as we are not a crazy litigious society (yet). We are immune from personal liability in the practice of our job, however our Ambulance service can be sued.

An Ambulance Officer here can be sued personally for negligence however they are protected by the Ambulance Services liability insurance. The Ambulance Service can be sued but this has never happened.

I might also add, while we do not have medical control, we are required and can consult for certain things. For example we cannot give fluids to paediatrics without a consult. However if we had in ICP with us, they would be able to give without consult.

Who are you consulting with; a duty ICP (Manager of some sort) or Dr Rashford?

 

[Outbac1]

Knock wood! We don't worry too much about lawsuits here. We have insurance and a number of very well qualified Emergency Medicine Drs to back us up. We would have to drop the ball big time to get sued. Most of us have enough education to not do that. You can justify doing or not doing a lot of things if you really want to.

So my question is how much does it cost to operate a good system? A system where there are a lot of ALS medics, approaching 50%. Other medics are way beyond EMT-B but not up to "Paramedic". A universal fleet, equipment and standards of practice.
Here we have about 950,000 people and our province, (state), pays about $100,000,000. per year for that system. It includes all ground ambulances.(approx 140), a helicopter, a fixed wing, and a modern dispatch center and about 850 medics. Thats not much more than $100.00 per person per year. We pay for it with a provincial "Health Services Tax" of 8% on most goods at the point of sale. This tax generates way more money than what is needed for EHS. The rest goes for other health care.
Perhaps Brown and the Aussies can chime in with what it cost to operate their state wide systems.

If your state has 10 million people, how much emergency health service could you buy for one billion $?

 

[MrBrown]

Ambulance cost around $180 million last year. That's to cover about 3.8 million people with ~500 vehicles, 1,000 paid Ambulance Officers, 2,500 volunteer Ambulance Officers, about 100 stations and attend, treat and/or transport over 370,000 patients.

Each year the Ambulance Service operates at a deficit and we expect it to be about $15 million this year

 

[the_negro_puppy]

An Ambulance Officer here can be sued personally for negligence however they are protected by the Ambulance Services liability insurance. The Ambulance Service can be sued but this has never happened.


Really? QAS gets sued all the time lol. Multiple suits every year. We have legal lectures at most of our training workshops.


Who are you consulting with; a duty ICP (Manager of some sort) or Dr Rashford?

Generally we are told to consult with a hospital emergency doctor- We have phone numbers for consultants at the major hopsitals. I have never needed to or been on a case that needed a consult, its pretty rare, coz the drugs needing a consult rarely get used for the circumstances needing consult.




Our service serves 4 million people over 1.77 million square kilometres. From July to December last year we did 398, 240 cases. Unsure of budget will have to dig around

 

[Melclin]

I'd like to point out that there is a difference between medical control in the sense of calling and asking for your 2mg of morphine every 15 mins, and medical direction in the sense that doctors are part of a team of experts who come up with a bunch of best practice standards to follow.

Scrapping online medical control and expecting American paramedics to do some thinking isn't a bad idea. But its absurd to suggest that physicians and indeed other HCPs wouldn't be involved in building accepted standards of practice.

 

[mycrofft]

In USA there is even absentee medical control.

Sign the contract, and some MD in Florida or Delaware will review your paperwork, answer legal correspondence, and come up with canned protocols.

Vene, I don't think "it" can be fixed, just our little corners of it one at a time. When it comes to fatcats lying about quality of care and pocketing millions, I get a little Bolshie.

 

[JJR512]

Saying that physicians don't know how to provide care minus the fancy tests and under stress (the underlying meaning of the line about "access to a wide variety of tests, treatments, and all the other benefits of practicing in a hospital") is like a physician calling paramedics "ambulance drivers" with the intent of honestly meaning that all they do is drive ambulances. So, yes, I'm a little bit sensitive to lines that discuss or imply that "physicians just don't understand EMS because they have access to an x-ray."

I never said that "physicians don't know how to provide care minus the fancy tests and under stress". You should know me well enough by now to know better than to try to find the subtext or "underlying meaning" of what I write. There isn't any, and if you try to argue with me based on what you think you find there you're just arguing with yourself. I never said they don't know how to provide care minus anything, I said that it's hard (practically impossible) for them to put that out of their mind and think like someone who doesn't have the knowledge and experience of a doctor.

And there's no need for you to be a little bit sensitive to something that you (mistakenly) perceive as an insult to physicians, because you're not a physician so it's not like you're being insulted.

While I agree that physicians can catch things easier because of our education/training, that doesn't mean that we expect everyone to pick up everything, especially the zebras. However, there's a huge difference between not picking up a final diagnosis and not picking up either what should be blatantly obvious, or patients who need to go to the hospital for a further workup. If paramedics are constantly electing to not transport patients who should get a further workup (let me point to Mr. Chest Pain case or Mr. HS athlete case above) or missing the blatantly obvious life threatening emergencies (otherwise known as their job), then I have to question if it's worth it to defend them under the status quo. Yes, I have faith that most physicians expect, at most, that paramedics and EMTs are supposed to be capable at their given the educational and diagnostic limitations and can differentiate what is reasonable. Not considering a pulmonary embolism as a potential cause of chest pain should not be an unreasonable expectation of a paramedic.

You're talking about specific situations or scenarios here as if that disproves anything I said. My statement was a very broad, simple, general statement that cannot be disproven by a few specific situations, which are known as exceptions.

Who should then? Would you rather have your care judged by someone who barely passed high school who seriously believes in protocols as cookbooks?

First of all, we are not talking about judging, we are talking about providing expert testimony. The judge or jury does the judging, the expert witness provides the expert testimony.

Secondly, if I follow the protocols as a "cookbook" and the patient dies and I'm accused of negligence, then you're damned right I'd want another EMS provider who also follows the protocols as a "cookbook" to testify that what I did is exactly what he would have done, too.

Alternatively, if one can reason that, while obvious to a physician, may not be obvious to a paramedic, why would he or she be unable to articulate that in a court of law? Just about all of the malpractice cases I've heard about are either acts of gross stupidity or failures in technique. I can't recall any time that I've seen a suit for, say, misdiagnosing a pericarditis as an MI. Similarly, yes. I think a physician could validly say that a paramedic should be able to catch an esophageal intubation, regardless of the technology available. After all, it's infinitely more likely to be sued for not correcting an esophageal intubation than intubating (but catching and correcting) an esophageal intubation.

Sorry, I don't understand the question ("Alternatively, if one can reason that, while obvious to a physician, may not be obvious to a paramedic, why would he or she be unable to articulate that in a court of law?") There seems to be at least one word missing in there somewhere, I'm not sure if the "he or she" is referring to the physician or the paramedic, and I'm not sure what the "that" in "articulate that" is referring to. But in any event, again, you're providing a specific example that doesn't really disprove anything.

The fact of the matter is what we're talking about here, in this post and the chain of posts in this thread that lead to where we are now, is negligence. I've already provided the definition of negligence, and may I remind you that it says the care provided by the accused is to be compared with the standard of care that would be rendered by another reasonably prudent person in the same profession. Is a doctor in the profession of prehospital EMS? No. It's that simple.

The problem is that then we have the stupidity of "everyone with a trauma get's a backboard" or "everyone gets oxygen" because that's the classroom "standard of care."

Maybe in your classroom but not in mine, and I just completed an EMT-B course for the second time (after letting my original certification lapse). We most definitely were taught that backboarding can do more harm than good if it isn't needed, and we were taught when to recognized when it is and isn't needed. We were taught that for the purposes of the exams, every patient gets oxygen because every patient scenario in the exams have been designed to require oxygen. We were also taught that in the real world, not every patient requires oxygen. We were taught to never withhold it if the patient actually asks for it, but otherwise, administer only if it seems needed, with "seems needed" being based on SpO2, appearance, assessment, complaint, work of breathing, etc.

 

[JPINFV]

First of all, we are not talking about judging, we are talking about providing expert testimony. The judge or jury does the judging, the expert witness provides the expert testimony.

That expert testimony requires the expert to make a decision, and subsequent argument, about whether the actions of the defendant are reasonable based on the standard of care and the science available (which are not necessarily the same thing as standard of care lags behind new science). There's a difference between "judging" in the sense of running a trial, "judging" in the sense of guilty/not guilty, and "judging" an action as reasonable/unreasonable based on the standards of the field. If the judge and jury were able to do that, there would be no need for an expert witness. I guarantee that one of the questions that the expert witnesses (plural since I'm willing to bet that both the defense and plaintiff will bring their own) will be asked, "In your opinion, was the care rendered acceptable?"

Secondly, if I follow the protocols as a "cookbook" and the patient dies and I'm accused of negligence, then you're damned right I'd want another EMS provider who also follows the protocols as a "cookbook" to testify that what I did is exactly what he would have done, too.

"Superior orders" is not a defense I would like to use in a court of law if the orders are manifestly wrong. That defense won't stand if the plaintiff can show that the EMS providers should have known better. All that would be shown was that there are two EMS providers who don't know how to do their job properly.

Also, if EMS providers are supposed to follow protocols to a T, why even provide 1000 hours of training? If the end all/be all is symptom relief based care based on a cookbook, than very little actual training is needed. There's definitely no need for foundation sciences (A/P, pharm, etc) in that case, since there's no reason to use it. Under this concept, I can train an EMT in a week, part time.

Sorry, I don't understand the question ("Alternatively, if one can reason that, while obvious to a physician, may not be obvious to a paramedic, why would he or she be unable to articulate that in a court of law?") There seems to be at least one word missing in there somewhere, I'm not sure if the "he or she" is referring to the physician or the paramedic, and I'm not sure what the "that" in "articulate that" is referring to. But in any event, again, you're providing a specific example that doesn't really disprove anything.

If the physician can understand that the educational background underlying a paramedic's practice of prehospital emergency medicine is not the same as the physician's educational background in emergency medicine, why can't the physician apply that understanding when providing expert testimony.

The fact of the matter is what we're talking about here, in this post and the chain of posts in this thread that lead to where we are now, is negligence. I've already provided the definition of negligence, and may I remind you that it says the care provided by the accused is to be compared with the standard of care that would be rendered by another reasonably prudent person in the same profession. Is a doctor in the profession of prehospital EMS? No. It's that simple.

Who determines what the standard of care under that set of protocols is?

Maybe in your classroom but not in mine, and I just completed an EMT-B course for the second time (after letting my original certification lapse). We most definitely were taught that backboarding can do more harm than good if it isn't needed, and we were taught when to recognized when it is and isn't needed. We were taught that for the purposes of the exams, every patient gets oxygen because every patient scenario in the exams have been designed to require oxygen. We were also taught that in the real world, not every patient requires oxygen. We were taught to never withhold it if the patient actually asks for it, but otherwise, administer only if it seems needed, with "seems needed" being based on SpO2, appearance, assessment, complaint, work of breathing, etc.

First off, again, who determines the standard of care? If the standards that licensing/certification exams (since, in many areas, the NREMT exam is the de facto licensure exam for that state), does high concentration supplemental oxygen administration being a critical failure for NREMT practicals (which includes behavioral, which based on the sample scenario (PDF page 21) wouldn't have any oxygen indicated. Most of the rest aren't really indications for more than a NC in the absence of a pulse ox) mean anything? After all, those are the standards you're being tested on. What about AHA recommendations? Those play a part in determining the standard of care, and the sample cardiac scenario provided definitely doesn't indicate oxygen therapy under the 2010 guidelines.

Why would you administer a medication only because the patient requested it? Isn't the EMS provider the professional providing care? What other drugs are going to be administered only on patient request absent any indication for use? "Gee, Mr. Paramedic. I'm in no pain, but I'd sure like a bolus of morphine."

So you were taught that backboards weren't necessary for all patients. Was it NEXUS or Canadian C-Spine rule? What if your system doesn't support the use of it? So you were taught one standard and are now being held to a different standard based on protocol, which is right? What if the expert witness EMS provider works in another system that does the opposite (either does or does not allow for selective spinal immobilization)? Who's setting the standard of care in that case?

So your class taught the material correctly from a medical standpoint, but how many other classes in your area teach the mentality of everyone gets oxygen and a backboard? One problem with the standard of care being the sole judge is that there's a certain amount of 'majority rule' involved. The majority, however, is not always right.