Re: DOS/Assessment

[Guest guest]

I would like to hear more about the ethics of the paramedic/corpse

relationship as it pertains to HIPAA.

Bledsoe, DO, FACEP

Midlothian, TX

[http://www.bryanbledsoe.com]

[Guest guest]

I would like to hear more about the ethics of the paramedic/corpse

relationship as it pertains to HIPAA.

Bledsoe, DO, FACEP

Midlothian, TX

[http://www.bryanbledsoe.com]

[Guest guest]

I would like to hear more about the ethics of the paramedic/corpse

relationship as it pertains to HIPAA.

Bledsoe, DO, FACEP

Midlothian, TX

[http://www.bryanbledsoe.com]

[Guest guest]

I don't know who's advising the County ME, but to my knowledge there

is NO legal authority for an EMT of any level in Texas to pronounce a patient.

As aforesaid, the persons who have that power are: (1) Justice of the Peace,

(2) Medical Examiner, (3) MD or DO, and (4) RN at hospice or NH with specific

delegation from physician.

Pronouncement of Death is one of those medical/legal things. Actually, it's

more legal than medical. It's necessary for the legal process of property

distribution to begin. No matter how long you've been buried, or even it you've

been cremated, you're not legally dead until a valid Death Certificate, signed

by one of the persons designated by the Texas Legislature to do so, attests

to it.

I would not advise any MD/DO to pronounce anybody based upon anything other

than eyeball contact with the decedent. Nor would I advise any EMT of any

level to " pronounce " a patient.

EMTs may withhold resuscitation based upon a medical determination that it

would be futile, but that is not a death pronouncement. It is a recognition of

death, but not a pronouncement of death. These are nuances, I realize, but no

EMT of whatever level in Texas can sign a Death Certificate.

If what y'all are saying about the practices in County are correct,

and I have no reason to doubt you, County is engaging in a practice that

has no basis in law.

Wes, ? Any comments? Am I missing anything?

GG

[Guest guest]

Gene,

My thoughts exactly! I didn't word it as such, but my response had the

same resound when I offered it to the supervisor who counseled me on the

matter. Oh well. I don't agree with it, but as long as they dispatch

me to it, I have to go.

Mike

[Guest guest]

Gene,

My thoughts exactly! I didn't word it as such, but my response had the

same resound when I offered it to the supervisor who counseled me on the

matter. Oh well. I don't agree with it, but as long as they dispatch

me to it, I have to go.

Mike

[Guest guest]

IMHO the " whys " would certainly explain your strip if documented, but the

strip adds nothing. If your patient is in rigor, then why on earth would you

need a strip to demonstrate death? As I said in an earlier post, people were

recognized as dead from the beginning of time up to about the middle of the last

century without the aid of an electrocardiogram. So what is happening here?

Fuzzy thinking, that's what. If one thinks critically about the practice of

demanding that EMS run a strip on a dead person, it makes no sense whatsoever.

It's an example of a failure of LE to think critically about what it is that

they're up to. It may be harmless, but then again, it may not be.

For instance, time of death can be very important in both criminal and civil

cases. Whereas the LE folks are thinking that a strip showing asystole

demonstrates death beyond a reasonable doubt, the medical folk, when questioned

under oath would be constrained to say that asystole does not necesarrily prove

irreversible death.

If one is being sued for causing the death of another, the argument might be

made that the patient wasn't actually dead and might have been resuscitated if

only the EMS people on scene had chosen to work the asystoly protocol.

Experts would come out of the woodwork to testify about the patients who were in

asystole, had CPR, Beta 1 agonist drugs and vagolytic drugs administered, and

progressed to ventricular fibrillation and were then shocked into a perfusing

rhythm.

Failure of EMS to resuscitate might be, farfetched as it may sound, used as

a defense in a murder case to show that but for the actions or inactions of

EMS the patient's injuries inflicted by the accused would not have resulted in

serious death.

Balderdash, you say! No jury would buy that. But they bought the OJ

defense, and they let Malvo go without the death penalty, all because of stuff

the

defense injected in the evidence.

I respect Mike a lot, and I certainly understand him when he says that when

he's dispatched to humor the LE folks he'll do it. But the LE folks are not

thinking straight or they wouldn't ask him to do it.

Now, on to HIPAA. HIPAA deals with medical records and the privacy of

individuals.

Once dead, you don't really have any rights to privacy; your privacy

interests devolve to your legal heirs.

I'm not aware that CMS has made any sort of ruling about the disclosure of

ECG strips of a deceased individual. Without a lot of research and study, my

initial reaction is that the same rules for disclosure to LE would apply after

death as before death.

If you study HIPAA, it grants LE the privilege of requesting individually

identifiable health information which is protected in certain emergency

situations, and it allows disclosure by the holders of that information in very

limited

circumstances.

I can't see that an ECG strip showing asystole would be necessary for LE to

do its job under any circumstance. Nor can I think of any interest of the

deceased or its heirs in preserving the ECG privacy of a deceased patient. So

that looks like even money.

This discussion may be the equivalent of debating how many angels can dance

on the head of a pin, but we oughtn't encourage fuzzy, imprecise thinking in

any discipline, law enforcement included. Our quest here is for the truth,

distilled and presented in its most basic and fundamental forms. We discuss

these

things in order to arrive at a better understanding of our craft. There are

no sacred cows here, nor any sacred ideas.

I hope that anyone who has a different idea of the value to LE of an ECG

strip showing asystole will speak up. There may well be some aspect of this

that

I'm not seeing. But from my present perch, I can see no reason for LE to ask

EMS to apply the monitor to an obviously dead person to confirm the death.

GG

In a messsage dated 12/26/2003 7:05:04 PM Central Standard Time,

EMSRECRUITER@... writes:

> so what if you do an EKG strip and it shows asystole... but on your

> documentation it shows that the pt has been down for x amt of time, with

> pooling, and or rigor mortis; does this documentation not cover the

> why's???

> what does hippa say about giving strips to LE?

>

> _________________________________________________________________

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>

>

>

>

[Guest guest]

so what if you do an EKG strip and it shows asystole... but on your

documentation it shows that the pt has been down for x amt of time, with

pooling, and or rigor mortis; does this documentation not cover the

why's???

what does hippa say about giving strips to LE?

_________________________________________________________________

Tired of slow downloads? Compare online deals from your local high-speed

providers now. https://broadband.msn.com

[Guest guest]

so what if you do an EKG strip and it shows asystole... but on your

documentation it shows that the pt has been down for x amt of time, with

pooling, and or rigor mortis; does this documentation not cover the

why's???

what does hippa say about giving strips to LE?

_________________________________________________________________

Tired of slow downloads? Compare online deals from your local high-speed

providers now. https://broadband.msn.com

[Guest guest]

so what if you do an EKG strip and it shows asystole... but on your

documentation it shows that the pt has been down for x amt of time, with

pooling, and or rigor mortis; does this documentation not cover the

why's???

what does hippa say about giving strips to LE?

_________________________________________________________________

Tired of slow downloads? Compare online deals from your local high-speed

providers now. https://broadband.msn.com

[Guest guest]

Hatfield (Home) wrote:

>

> >>> what does hippa say about giving strips to LE?

>

> Good question, but since they (LE) already have knowledge of their (the

> patients) immediate medical condition, i.e. that they are dead, it seems to

> me that you are not offering any HIPPA protected information.

Hmmm... seems like the definition of the term, " patient " could be

challenged here since a corpse, by Texas law, is not a person. This

would vary with the circumstances of the case, but it seems that in

circumstances where the medic is requested to run a strip simply for

evidenciary purposes, and is not used for the basis of the medic's death

determination, there is a valid argument that this corpse was not a

patient, thereby eliminating HIPPA constraints? No?

Rob

[Guest guest]

so what if you do an EKG strip and it shows asystole... but on your

documentation it shows that the pt has been down for x amt of time, with

pooling, and or rigor mortis; does this documentation not cover the

why's???

what does hippa say about giving strips to LE?

_________________________________________________________________

Working moms: Find helpful tips here on managing kids, home, work — and

yourself. http://special.msn.com/msnbc/workingmom.armx

[Guest guest]

so what if you do an EKG strip and it shows asystole... but on your

documentation it shows that the pt has been down for x amt of time, with

pooling, and or rigor mortis; does this documentation not cover the

why's???

what does hippa say about giving strips to LE?

_________________________________________________________________

Take advantage of our limited-time introductory offer for dial-up Internet

access. http://join.msn.com/?page=dept/dialup

[Guest guest]

I cannot remeber the exact part of the bill, but HIPPA specifically excludes

" dead persons " .

Ralph , LP

Mike Schadone wrote:

LE is NOT entitled to an EKG strip, I do believe. Do the HIPAA experts

want to weigh in???

Mike Schadone

[Guest guest]

You, in fact answered your own question. In County, paramedics

have a *specific delegation* from their medical director to pronounce

a patient w/ physician oversight. There are stipulations of course

(calling EMS Communications on a recorded line, etc) but just as RNs

are granted the authority under the auspices of a physician currently

licensed to practice medicine in Texas, paramedics also fall under the

same practice if approved by medical direction.

Regards,

Alfonso R. Ochoa, NREMT-P

> I don't know who's advising the County ME, but to my

knowledge there

> is NO legal authority for an EMT of any level in Texas to pronounce

a patient.

> As aforesaid, the persons who have that power are: (1) Justice of

the Peace,

> (2) Medical Examiner, (3) MD or DO, and (4) RN at hospice or NH with

specific

> delegation from physician.

>

> Pronouncement of Death is one of those medical/legal things.

Actually, it's

> more legal than medical. It's necessary for the legal process of

property

> distribution to begin. No matter how long you've been buried, or

even it you've

> been cremated, you're not legally dead until a valid Death

Certificate, signed

> by one of the persons designated by the Texas Legislature to do so,

attests

> to it.

>

> I would not advise any MD/DO to pronounce anybody based upon

anything other

> than eyeball contact with the decedent. Nor would I advise any EMT

of any

> level to " pronounce " a patient.

>

> EMTs may withhold resuscitation based upon a medical determination

that it

> would be futile, but that is not a death pronouncement. It is a

recognition of

> death, but not a pronouncement of death. These are nuances, I

realize, but no

> EMT of whatever level in Texas can sign a Death Certificate.

>

> If what y'all are saying about the practices in County are

correct,

> and I have no reason to doubt you, County is engaging in a

practice that

> has no basis in law.

>

> Wes, ? Any comments? Am I missing anything?

>

> GG

>

>

>

[Guest guest]

Gene,

We (in ) are not " pronouncing " . We are " determining " . After the

determination of death, we call a MC doc on the phone (or radio),

provide them with our assessment and they provide a time of death. If

there are signs of irreversible death, we do not begin ANY attempt at

resuscitation (and that includes an EKG strip). Also, we do not

transport corpses, so all codes are typically worked onscene until a

ROSC or efforts are noted to be futile (at which time we go into the

irreversible death determination and call the doc). The very few times

that we transport include CA at a public gathering and other times where

it would benefit the mitigation of the scene.

I hope that clarifies.

Mike

[Guest guest]

If you connect an EKG, it is assumed that you have begun treatment (EKG

is a medical diagnostic device used to guide treatment modalities).

Therefore, it would be easy to point out that the signs of irreversible

death might not have been so apparent (i.e. the times when you begin

treatment then notice rigor and cease efforts). This could be used in a

court of law to confuse the jury and possibly discredit a witness

(including the paramedic). From my training, I have consistently been

told that there is no evidence that an EKG should determine death aside

from " prolonged asystole during ACLS efforts " .

Mike

[Guest guest]

Okay. So, maybe I shouldn't have referred to the attorneys on this list

as " the HIPAA experts " . LE is not entitled to any documentation aside

from my name, number, unit, time of death and doc pronouncing. They are

not entitled to ANY of our documentation without a subpoena or warrant

for such specifically. I am not sure why, but I do know that it is not

pertinent to the investigation. LE is not trained to read an EKG,

therefore they have no use for it.

Anyone know of any specifics on why?

Mike

RE: DOS/Assessment

I cannot remeber the exact part of the bill, but HIPPA specifically

excludes " dead persons " .

[Guest guest]

Alfonso,

Can you cite me the statute that gives paramedics this authority? I can't

find it and I don't find it in the statutes. I don't believe that's true in

Texas.

We have visited this issue before with the legislature and stringently

opposed adding EMTs to the list of folks who can pronounce. Unless the

legislature

passed one of those special " for County only " bills that it loves so

much, I doubt very much that this authority exists.

If you have found something different, please let me know so that I can

update my notes.

Best,

Gene

In a message dated 12/26/2003 11:45:51 PM Central Standard Time,

asclapius@... writes:

> You, in fact answered your own question. In County, paramedics

> have a *specific delegation* from their medical director to pronounce

> a patient w/ physician oversight. There are stipulations of course

> (calling EMS Communications on a recorded line, etc) but just as RNs

> are granted the authority under the auspices of a physician currently

> licensed to practice medicine in Texas, paramedics also fall under the

> same practice if approved by medical direction.

>

> Regards,

>

> Alfonso R. Ochoa, NREMT-P

>

>

> > I don't know who's advising the County ME, but to my

> knowledge there

> > is NO legal authority for an EMT of any level in Texas to pronounce

> a patient.

> > As aforesaid, the persons who have that power are: (1) Justice of

> the Peace,

> > (2) Medical Examiner, (3) MD or DO, and (4) RN at hospice or NH with

> specific

> > delegation from physician.

> >

> > Pronouncement of Death is one of those medical/legal things.

> Actually, it's

> > more legal than medical. It's necessary for the legal process of

> property

> > distribution to begin. No matter how long you've been buried, or

> even it you've

> > been cremated, you're not legally dead until a valid Death

> Certificate, signed

> > by one of the persons designated by the Texas Legislature to do so,

> attests

> > to it.

> >

> > I would not advise any MD/DO to pronounce anybody based upon

> anything other

> > than eyeball contact with the decedent. Nor would I advise any EMT

> of any

> > level to " pronounce " a patient.

> >

> > EMTs may withhold resuscitation based upon a medical determination

> that it

> > would be futile, but that is not a death pronouncement. It is a

> recognition of

> > death, but not a pronouncement of death. These are nuances, I

> realize, but no

> > EMT of whatever level in Texas can sign a Death Certificate.

> >

> > If what y'all are saying about the practices in County are

> correct,

> > and I have no reason to doubt you, County is engaging in a

> practice that

> > has no basis in law.

> >

> > Wes, ? Any comments? Am I missing anything?

> >

> > GG

> >

> >

> >

[Guest guest]

There are still some JP's, at least in our area, who want a strip, who knows

why, yet we oblige them.

In so much as ending up in court with a strip of asystole as a treatable

rythm, my answer would be, " No sir/maam. asystole is NOT a treatable rythm

when found in conjunction with the other signs and symptoms that I observed

and noted in my report, i.e. rigor mortis, lividity, decapitation, etc. "

Mike

> I'm with Gene. The HIPPA issue with the ECG strip on a dead person is a

non-

> issue because you really shouldn't be running an asystole strip to prove

> death. Asystole is a potentially " treatable " rhythm based on the AHA

> guidelines, which could be used against you in a courtroom when they ask

> you, " So, Mr. , what IS the interpretation of this strip? And isn't

it

> true that you have a protocol to treat asystole? So why didn't you follow

> it? Why did you leave this person to die with a treatable rhythm by your

own

> protocols?? " That is NOT a position I want to be in....

>

> Jane Hill

>

>

>

>

>

>

[Guest guest]

There are still some JP's, at least in our area, who want a strip, who knows

why, yet we oblige them.

In so much as ending up in court with a strip of asystole as a treatable

rythm, my answer would be, " No sir/maam. asystole is NOT a treatable rythm

when found in conjunction with the other signs and symptoms that I observed

and noted in my report, i.e. rigor mortis, lividity, decapitation, etc. "

Mike

> I'm with Gene. The HIPPA issue with the ECG strip on a dead person is a

non-

> issue because you really shouldn't be running an asystole strip to prove

> death. Asystole is a potentially " treatable " rhythm based on the AHA

> guidelines, which could be used against you in a courtroom when they ask

> you, " So, Mr. , what IS the interpretation of this strip? And isn't

it

> true that you have a protocol to treat asystole? So why didn't you follow

> it? Why did you leave this person to die with a treatable rhythm by your

own

> protocols?? " That is NOT a position I want to be in....

>

> Jane Hill

>

>

>

>

>

>

[Guest guest]

>>> so what if you do an EKG strip and it shows asystole... but on your

>>> documentation it shows that the pt has been down for x amt of time, with

>>> pooling, and or rigor mortis; does this documentation not cover the

>>> why's???

It should, the thing we all have to realize is that each of us operates

under a different medical director who may or may not dictate that a strip

must be run. If that's the case, all the cussing and discussing we do on

here about not having to run one si a moot point until they (MD's) can see

that doing so is a fruitless effort.

Document, document, document.

Some have JP's that insist upon a strip (as we do here), and others have LE

that insist on it. I don't need one if there are obvious signs of death, I

don't feel a need to run a strip " because that's the way it's always been

done " . Someone wrote that their LE actually called a neighboring service to

run a strip when they wouldn't. Is this not the epitome of a waste of

resources? Not entirely sure what LE will do with the strip, perhaps it's a

reflection on the 'flat line' theory. Unless they see a flat line, they are

not convinced that they are dead.

Personally, as long as it does not take away from my job, I really don't

mind running a strip, confirming it for them, and going on about my merry

way, it takes all of about 2 minutes and 12 " of tape for me to

diplomatically say, " I told you so, they really are dead. " Just because I

run one for the JP, does not mean I will keep one for myself and attach it

to the run report, again, I see no need.

As Gene so eloquently put it, " Could you not tell the patient was dead by

the mere fact that his head was greater than 3 feet from the rest of the

remains? "

>>> what does hippa say about giving strips to LE?

Good question, but since they (LE) already have knowledge of their (the

patients) immediate medical condition, i.e. that they are dead, it seems to

me that you are not offering any HIPPA protected information.

Those in the know may correct me, and I am curious about that myself.

Mike

[Guest guest]

>>> so what if you do an EKG strip and it shows asystole... but on your

>>> documentation it shows that the pt has been down for x amt of time, with

>>> pooling, and or rigor mortis; does this documentation not cover the

>>> why's???

It should, the thing we all have to realize is that each of us operates

under a different medical director who may or may not dictate that a strip

must be run. If that's the case, all the cussing and discussing we do on

here about not having to run one si a moot point until they (MD's) can see

that doing so is a fruitless effort.

Document, document, document.

Some have JP's that insist upon a strip (as we do here), and others have LE

that insist on it. I don't need one if there are obvious signs of death, I

don't feel a need to run a strip " because that's the way it's always been

done " . Someone wrote that their LE actually called a neighboring service to

run a strip when they wouldn't. Is this not the epitome of a waste of

resources? Not entirely sure what LE will do with the strip, perhaps it's a

reflection on the 'flat line' theory. Unless they see a flat line, they are

not convinced that they are dead.

Personally, as long as it does not take away from my job, I really don't

mind running a strip, confirming it for them, and going on about my merry

way, it takes all of about 2 minutes and 12 " of tape for me to

diplomatically say, " I told you so, they really are dead. " Just because I

run one for the JP, does not mean I will keep one for myself and attach it

to the run report, again, I see no need.

As Gene so eloquently put it, " Could you not tell the patient was dead by

the mere fact that his head was greater than 3 feet from the rest of the

remains? "

>>> what does hippa say about giving strips to LE?

Good question, but since they (LE) already have knowledge of their (the

patients) immediate medical condition, i.e. that they are dead, it seems to

me that you are not offering any HIPPA protected information.

Those in the know may correct me, and I am curious about that myself.

Mike

[Guest guest]

>>> so what if you do an EKG strip and it shows asystole... but on your

>>> documentation it shows that the pt has been down for x amt of time, with

>>> pooling, and or rigor mortis; does this documentation not cover the

>>> why's???

It should, the thing we all have to realize is that each of us operates

under a different medical director who may or may not dictate that a strip

must be run. If that's the case, all the cussing and discussing we do on

here about not having to run one si a moot point until they (MD's) can see

that doing so is a fruitless effort.

Document, document, document.

Some have JP's that insist upon a strip (as we do here), and others have LE

that insist on it. I don't need one if there are obvious signs of death, I

don't feel a need to run a strip " because that's the way it's always been

done " . Someone wrote that their LE actually called a neighboring service to

run a strip when they wouldn't. Is this not the epitome of a waste of

resources? Not entirely sure what LE will do with the strip, perhaps it's a

reflection on the 'flat line' theory. Unless they see a flat line, they are

not convinced that they are dead.

Personally, as long as it does not take away from my job, I really don't

mind running a strip, confirming it for them, and going on about my merry

way, it takes all of about 2 minutes and 12 " of tape for me to

diplomatically say, " I told you so, they really are dead. " Just because I

run one for the JP, does not mean I will keep one for myself and attach it

to the run report, again, I see no need.

As Gene so eloquently put it, " Could you not tell the patient was dead by

the mere fact that his head was greater than 3 feet from the rest of the

remains? "

>>> what does hippa say about giving strips to LE?

Good question, but since they (LE) already have knowledge of their (the

patients) immediate medical condition, i.e. that they are dead, it seems to

me that you are not offering any HIPPA protected information.

Those in the know may correct me, and I am curious about that myself.

Mike