Re: Today's Challenge: OB/GYN Scenario

[Guest guest]

Thanks for your well thought out response. I hope others will reply

in as astute a fashion.

Some questions for you and others based upon your responses. Suppose we rule

the medics out as potential defendants. Could the service still be liable

for failure to carry an oxytocic agent? Could the medical director be found

liable for failure to provide standard of care?

Can your argument that not every drug taught in NSC needs to be carried,

citing Levophed, be counteracted by pointing out that most services carry

dopamine

which has similar qualities to Levophed, whereas the services that do not

carry an oxytocic agent do not have another substitute?

Is it a valid argument that since few services now carry an oxytocic agent,

it is no longer standard of care? What can be said about the services that do

carry methergine or oxytocin?

Is there a significant difference between SOC in an urban area with short txp

times to hospital and rural/frontier services where txp times are prolonged?

Is the situation presented in the scenario foreseeable? Would the carrying

of an oxytocic drug be prohibitively costly? Are there shelflife or

temperature considerations that are any different from other drugs such as

succinylcholine?

If your service carries haloperidol but hasn't used it in 5 years, is that

fact relevant when compared with failure to carry oxytocin, for example, to

the argument that we don't carry drugs we're unlikely to use?

These are the questions that the lawyer who has hired you as an expert asks.

How will you answer her or him?

GG

[Guest guest]

The components of negligence are 1) a duty to act, 2) a breech of that

duty, and 3) damages or losses derived from the breech of duty.

The crew responded in a timely fashion (I am assuming is stipulated),

provided appropriate care following the local standards that they

operate from, and performed those duties in good faith (as the

procedures outlined in their SOC's or Protocols are approved by an

appropriate physician). I do not believe that this crew can be held

personally liable for not having the equipment to deal with this

particular emergency unless said tools were to be part of the stocking

list for their particular ambulance.

As for the reasonableness of the service providing medications to

mitigate such an affliction, I believe that can be argued. But, it is

well known that pitocin is not carried by the majority of EMS

organizations around the country (to my knowledge), though it remains a

part of the Nat'l Standard for training (again, so does Levophed).

I think a good example of negligence is the use of non-latex equipment.

If a person calls for EMS and states that they have an allergy to latex,

then there is a duty of the EMS providers to not introduce latex into

the patient's environment. If they do utilize latex in their care, then

they have breeched that duty. Unless this breech is detrimental to the

patient, negligence does not exist. If the patient suffers an

anaphylactic reaction and it can be attributed to the use of latex, then

there is negligence.

With the patient mentioned in the email, there was an acceptable

standard that it appears the EMS providers treated her to. If pitocin

was readily available, then they may be a duty to act in regards to the

use of that medication. I believe, from the email, that pitocin was not

available (and, I only mention pitocin because methergine is not in the

Nat'l Standard for EMS, as far as I know). In this case, the EMS

providers cannot be held liable to the lack of pitocin (unless, of

course, it is included as a stocking item on the truck and it was either

unavailable or not restocked properly). Going on this principle is

dangerous. There are numerous medications that could have assisted in

this patient's recovery if made available to EMS. The one thing that

comes to mind is Hetastarch. This is an approved fluid used to

hemorrhagic shock in and may have helped. I still don't feel that a

lack of these things should be tantamount to a case of negligence,

though.

My concern would be the clinical picture of shock. Did the EMS

providers treat the shock appropriately (Trendelenberg, appropriate IV

fluid challenge, et al.)? Did they use an acceptable means to attempt

to control the bleeding? Did they meet the standard as laid out in

their protocols or Standards of Care? Would another peer working under

the same set of guidelines in the same circumstances treat this patient

in the same fashion? Also, was this patient under the care and

supervision of an OB/GYN that has stated to her a risk of injury with

the performance of her daily life (i.e. was it recommended to her that

she should " take it easy " or " stay in bed " ?). This would amount to her

loss being an avoidable consequence.

I believe that there may be a case against the service provider

administration and the medical director, though, I'm not sure it would

be worth pursuing. There are reasons why these medications, fluids and

tools were not available, and if the reasons behind this are reasonable

(cost, lack of proven efficacy, inability to adequately store, et al.),

then there would be no case.

Now, I will say that, although I have been involved in some medico-legal

discussions here, I am neither a lawyer, nor do I practice law. I am

just citing some general law concepts (not necessarily Texas Law or

Federal Law). I also do not know of any case law that can be cited. I

have supplied some definitions below that are commonly used in these

types of cases. It is my thought that this case may provoke some well

thought out responses.

Negligence: The failure to exercise the care of a reasonably prudent or

ordinarily careful person in the circumstances; a breach of the duty to

act with care appropriate to the situation and the relationship of the

persons, so as not to cause harm or loss.

Gross Negligence: Negligence beyond the ordinary; a reckless or wanton

disregard of the duty of care toward others.

Comparative Negligence: The apportionment of fault when both the

plaintiff and the defendant contributed to a loss by failing to exercise

the required degree of care. Damages for the plaintiff are decreased in

proportion to his or her own negligence.

Contributory Negligence: An injured person's failure to exercise due

care, which along with another person's (the defendant's) negligence,

contributed to the injury. A common law defense, originating in England,

that one who negligently harms another cannot be found liable if the

injured person himself was negligent in the slightest degree. This

defense was often used by employers in suits brought by injured workers.

Workers' compensation laws made the defense inapplicable to claims for

compensation; it is available only if an employee waives his

compensation claim and instead sues an employer in tort. Many states

have adopted a comparative or proportional form of contributory

negligence whereby negligence of the injured person is not a complete

defense, but reduces the defendant's liability according to the degree

of the plaintiff's negligence.

Avoidable Consequence: An adverse result that arises from a lack of

care, especially on the part of a person who suffers a harm or loss.

Under this concept, a plaintiff cannot recover damages for injuries or

losses that could have been avoided or mitigated by using reasonable

care.

Degree of Care: The level of caution, prudence or forethought legally

required to avoid causing harm or loss to another person. In determining

liability, depending on the circumstances and the relationship of the

persons involved, a person may be required to exercise degrees of care

variously described as " ordinary, " " due, " " reasonable, " " great, " or

" utmost. " Failure to meet the applicable standard constitutes a breach

of duty in the corresponding degree--e.g., ordinary negligence, gross

negligence, recklessness, wanton or willful misconduct, etc.

Schadone, NREMT-Paramedic

City of Austin

Austin/ County EMS

Medic 12 / Medic 24

@...

Today's Challenge: OB/GYN Scenario

Let's say that your patient, a 27 year old gravida 5 para 4 presents at

the

local laundromat with possible spontaneous abortion. You find your

patient in

the toilet. She relates a sudden onset of abdominal pain and uterine

contractions after which she felt an uncontrollable urge to move her

bowels. She went

to the toilet and felt the fetus moving. A fetus has been delivered

which

is still attached to the umbilical cord. The fetus appears to be of

consistent

GA with the 18 weeks that the patient relates and has an APGAR of 0/0/0.

Your patient is bleeding profusely from the vagina and complains of

weakness and

dizziness. She is also very emotionally upset and seems somewhat

confused.

He skin is pale and clammy. Carotid and radial pulses are 118, BP is

96/54,

respirations are 32 with 97% sat. You estimate blood loss as >500 ml.

Your

service is MICU and you are approximately 40-45 minutes by ground

ambulance to

the nearest hospital. Helicopter is not an option due to weather.

You place two large trauma dressings against the vaginal opening,

administer

O2 by NRB at 15 lpm, and begin transport, starting two IVs with NS.

enroute. Your patient continues to bleed, soaking the trauma dressings

within 3

minutes. You are massaging the uterus as trained. Your patient's LOC

drops from

15 GCS to 11 by the time you are 10 minutes into your transport. Pulse

rate at

this time is 136 with ST on the monitor, BP is 84/50, respirations are

30

with NRB/15/lpm, 98% sat. You are considering attempting to place a

nasotracheal

tube. You have diazepam, midazolam, sux and vecuronium on your truck.

You

do not have either methergine or pitocin.

Enroute your patient's condition worsens and she experiences a cardiac

arrest

36 minutes into your transport. You apply ACLS interventions according

to

your protocols and guidelines, and your efforts at resuscitation are not

an

issue. Your efforts at resuscitation fail but are continued for 10 more

minutes

until you arrive at the ED where after an additional 30 minutes or

attempted

resuscitation the patient is pronounced.

You are asked by a prominent plaintiff's malpractice attorney to review

the

case for possible liability. Specifically he wants to know whether or

not the

EMS service's failure to have either methergine or oxytocin on board

constitute a breach of standard of care, and whether or not it would be

reasonable for

an EMS service to have carried such drugs. He has obtained copies of

the PCRs

on the run, the service's policies and procedures, protocols, the

service's

drug formulary, records of CE presentations over the last two years,

education and training records of the Paramedic and EMT-I who were the

crew members

on the call, dispatch records and recordings, weather reports, USDOT

National

Standard Curriculum for Paramedics, the hospital ED records on the

patient

and the autopsy report finding cause of death to be " cardiac arrest

secondary

to massive uterine hemorrhage. "

Please review the case for the lawyer from your point of view as an EMT,

Paramedic, or Physician.

Advise the lawyer whether or not there is a reasonable probability that

the

potential defendants were guilty of any degree of negligence. Try to be

as

objective as possible and look at the case from both the plaintiff's and

defendant's perspectives. Keep in mind that the attorney does not want

to file a case

that is not winnable, but he does want to file if there is actual

malpractice.

There are ample damages that can be proved if negligence is established.

Best,

GG

Gene Gandy, JD, LP

EMS Educator and Consultant

HillGandy Associates

POB 1651

Albany, TX 76430

cell:

wegandy@...

wegandy1938@...

[Guest guest]

I would first have to ask if the medical director had as an approved drug

list those drugs not onboard (i.e., pitocin and methergine). If so this would

be

a breach of standard of care. Not a very good sign for the EMS service who

didn't make sure the drugs were there.

If not then I believe the plaintiff attorney would have to turn his

attention to the medical director and be forced to ask why this medical director

did

not feel it wise to put these drugs on board. Have other services not carried

these drugs? Possibly not a good case to pursue if these were the facts.

Danny L.

Owner/NREMT-P

Panhandle Emergency Training Services And Response

(PETSAR)

Office

FAX

[Guest guest]

Re: Today's Challenge: OB/GYN Scenario

>Thanks for your well thought out response. I hope others will

reply in as astute a fashion.

Well, thank you.

>Some questions for you and others based upon your responses. Suppose

we rule the medics out as potential defendants. >Could the service

still be liable for failure to carry an oxytocic agent? Could the

medical director be found liable for >failure to provide standard of

care?

The only way that I could imagine the medics as potential defendants

would be if they dilly-dallied onscene. Shock requires rapid transport

to the closest appropriate facility. Beyond that, if the medical

director or the service went around the standard (i.e. was so blatant to

have paramedics who didn't carry a defibrillator), then I feel that they

should be held liable. But, to not carry oxytocin or methergine. I

wouldn't fault them for that.

>Can your argument that not every drug taught in NSC needs to be

carried, citing Levophed, be counteracted by pointing out >that most

services carry dopamine which has similar qualities to Levophed, whereas

the services that do not carry an >oxytocic agent do not have another

substitute?

In regards to Levophed, we carry dopamine and epinephrine. My

experience with the three is that an epi drip concomitant with renal

doses of dopamine surpass the risk/benefit ratio of levophed alone. I'm

sure that in a hospital environment with renal docs paying close

attention, it's worth it, but not in the pre-hospital arena. As far as

oxytocin, maybe we require some research into alternative therapies that

may have more efficacy in the prehospital arena. There is obviously

some reason why most providers do not carry it.

>Is it a valid argument that since few services now carry an oxytocic

agent, it is no longer standard of care? What can >be said about the

services that do carry methergine or oxytocin?

I truly do not believe that oxytocin is a standard any longer. Though,

it may have a come back. It may also take litigation to find its new

place in our drug box.

>Is there a significant difference between SOC in an urban area with

short txp times to hospital and rural/frontier >services where txp times

are prolonged?

There is great difference between the standards for long vs. short

transport times. A good example of that is nifedipine. Rhode Island

has a protocol for the prehospital use of nifedipine. This protocol is

in place for one town and one town only. This particular town has one

of the longest transport times in the state. And, the use is strictly

limited to AMI's with a sustained systolic BP of > 200 or a diastolic BP

> 120. No other provider in the state will ever see the use of

nifedipine. The risks are too great.

>Is the situation presented in the scenario foreseeable? Would the

carrying of an oxytocic drug be prohibitively costly? >Are there

shelflife or temperature considerations that are any different from

other drugs such as succinylcholine?

The situation is very foreseeable in that we do not carry there

medications and the patient population that needs them will suffer.

But, will more suffer if we place the medication on the truck (cost

prohibition)? Is it practical to use this medication in that particular

service? What is the onset of action vs. the transport time? Is this

something that ultimately requires surgery to fix?

>If your service carries haloperidol but hasn't used it in 5 years, is

that fact relevant when compared with failure to >carry oxytocin, for

example, to the argument that we don't carry drugs we're unlikely to

use?

Yes, I believe that it could be. But, you also have to remember that

the state can tell them what to stock. Here in Austin, we carry

verapamil and nifedipine, but we do not have SOC's that govern their

use. We would have to request to use it from online medical control

(and, I doubt permission would be granted on the large scale). But, if

you could dig deep enough and find that there is a recurring need for

such medicines and they haven't figured it out or acknowledged the fact,

then there could be some negligent action on their part.

>These are the questions that the lawyer who has hired you as an expert

asks. How will you answer her or him?

Ultimately, it would take some gross and willful misconduct or

misrepresentation of the facts in order to convince me, personally.

There is usually no monetary gain from a medical director regarding the

use of certain drugs in the protocols. There is another point to make,

though. Is this particular medical director an " absent " one? If he/she

is, and he/she doesn't take a proactive interest in the service or its

protocols, then I could surmise that the medical director had a duty to

act (consideration of the current protocols and changing them as the

science and research dictates) and failed in that duty (disregarded all

of the science to make it easier on him or herself. laziness) and there

was a loss or damage resultant (the death of the unfortunate person in

your original email). That, I believe, could be tantamount to

malpractice and negligence.

Schadone, ABCD-EFG, NREMT-P, QRS, TUV, WXY & Z

[Guest guest]

I agree with Mr.. If the drugs are not a part of the protocol or the

approved drug list for the service, Then the attention should fall back on the

medical director, especially if these drugs are used as standard of care in the

field. The medical director is obligated to keep the paramedics and EMT up to

standards and participate in their continuing education and advancement in

providing a better standard of care. Unfortunately there are some that are

caught up in the political game and want to please the powers that be.

" De Opressa Liber "

JB

Re: Today's Challenge: OB/GYN Scenario

I would first have to ask if the medical director had as an approved drug

list those drugs not onboard (i.e., pitocin and methergine). If so this would

be

a breach of standard of care. Not a very good sign for the EMS service who

didn't make sure the drugs were there.

If not then I believe the plaintiff attorney would have to turn his

attention to the medical director and be forced to ask why this medical

director did

not feel it wise to put these drugs on board. Have other services not carried

these drugs? Possibly not a good case to pursue if these were the facts.

Danny L.

Owner/NREMT-P

Panhandle Emergency Training Services And Response

(PETSAR)

Office

FAX

[Guest guest]

I would have to ask at what point is the Medical Director out of the

liability noose? There are a lot of medications and devices on the market

that may be employed by some services and not by others. Some of these are

not affordable by all EMS systems, others are not cost effective.

Amiodarone comes to mind as an example. The Medical Director does not

always control the purse strings, so can she or she really be held liable if

the system decides not to purchase a drug or device?

Here in our system the Medical Director works very closely with the medical

community. Changes in our SOCs are reviewed by members of the local medical

society and by an advisory board prior to implementation. If our MD were to

approach these groups with a change that would place Pitocin on the trucks,

and the groups were not supportive of it, then the drug would most likely

not be placed on the trucks. In the given scenario, would the advisory

boards and medical society be liable for the outcome (or at least be named

in the suit)?

What kind of weather problems kept the helicopter from flying? I have been

on a ski slope in the Lake Tahoe area in near white-out conditions and saw a

medical helicopter land to pick up an injured skier. If it can happen

there, why not in the scenario? Would not the air service provider in the

scenario be negligent for not meeting a standard for IFR which is being used

by other services across the country?

Keep the thoughts coming.

Ed Strout, RN, CEN, LP

Clinical Practice Coordinator

Austin- County EMS

517 S. Pleasant Valley Rd.

Austin, Tx. 78741

Office

Pager

Fax

e-mail: ed.strout@...

Re: Today's Challenge: OB/GYN Scenario

I agree with Mr.. If the drugs are not a part of the protocol or the

approved drug list for the service, Then the attention should fall back on

the medical director, especially if these drugs are used as standard of care

in the field. The medical director is obligated to keep the paramedics and

EMT up to standards and participate in their continuing education and

advancement in providing a better standard of care. Unfortunately there are

some that are caught up in the political game and want to please the powers

that be.

" De Opressa Liber "

JB

Re: Today's Challenge: OB/GYN Scenario

I would first have to ask if the medical director had as an approved drug

list those drugs not onboard (i.e., pitocin and methergine). If so this

would be

a breach of standard of care. Not a very good sign for the EMS service

who

didn't make sure the drugs were there.

If not then I believe the plaintiff attorney would have to turn his

attention to the medical director and be forced to ask why this medical

director did

not feel it wise to put these drugs on board. Have other services not

carried

these drugs? Possibly not a good case to pursue if these were the facts.

Danny L.

Owner/NREMT-P

Panhandle Emergency Training Services And Response

(PETSAR)

Office

FAX

[Guest guest]

Ed,

I wouldn't describe what I write as belief, experience, or opinion. What I

write here is based upon a sort of Socratic method designed to elicit the

thoughts of others. I frankly don't know the answer to your question. Here's

what

I can add to your thoughts.

If the medical director were sued along with the service and it was his

position that he had recommended carrying the drug but management had refused,

then

he has a conflict in defense between himself and his employer. He could then

file what is known as a " cross action " against his employer alleging that he

was effectively prevented by them from doing due diligence and practicing

standard of care because they refused to purchase and carry the drug. He would

say that if he's liable, then they're liable for making him liable, and that

they therefore should stand for the judgment, not him. If the jury heard

evidence on that point, and there were sufficient records in the form of memos,

et

cetera, to back him up, then the jury might very well exonerate him and hold the

service and its managers liable.

This brings up another point. In a lawsuit it's every person for

him/herself. It doesn't take long for alliances to disappear when judgment

liability is

lurking.

So far there hasn't been any litigation that I'm aware of that has taken this

tack, but then we don't hear about cases that are settled or those that are

tried to a jury and not appealed. We only know about cases that are taken up

on appeal and have opinions published. Trial cases are almost never

published. Sometimes a judge will make a what he thinks is a significant ruling

on

evidence or a point of law in a case and request that the case publishers

publish

his opinion, but that's a very unusual occurrence.

Best,

GG

In a message dated 6/2/2003 5:28:41 PM Central Daylight Time,

ed.strout@... writes:

>

> Is it your belief (or experience, opinion, or whatever best describes your

> answer) that the " liability should also be with the medical director if the

> policy is found wanting, simply because it is the medical director who is

> the licensed practitioner " would hold true if the medical director wanted to

> carry the drug but the people with the money declined it? Also, as I

> mentioned earlier, changes to our SOCs are first approved by the local

> medical community. What if they didn't approve? What's your take on a

> scenario with these variables added?

>

> Ed Strout, RN, CEN, LP

> Clinical Practice Coordinator

> Austin- County EMS

> 517 S. Pleasant Valley Rd.

> Austin, Tx. 78741

> Office

> Pager

> Fax

> e-mail: ed.strout@...

>

>

[Guest guest]

Ed,

I wouldn't describe what I write as belief, experience, or opinion. What I

write here is based upon a sort of Socratic method designed to elicit the

thoughts of others. I frankly don't know the answer to your question. Here's

what

I can add to your thoughts.

If the medical director were sued along with the service and it was his

position that he had recommended carrying the drug but management had refused,

then

he has a conflict in defense between himself and his employer. He could then

file what is known as a " cross action " against his employer alleging that he

was effectively prevented by them from doing due diligence and practicing

standard of care because they refused to purchase and carry the drug. He would

say that if he's liable, then they're liable for making him liable, and that

they therefore should stand for the judgment, not him. If the jury heard

evidence on that point, and there were sufficient records in the form of memos,

et

cetera, to back him up, then the jury might very well exonerate him and hold the

service and its managers liable.

This brings up another point. In a lawsuit it's every person for

him/herself. It doesn't take long for alliances to disappear when judgment

liability is

lurking.

So far there hasn't been any litigation that I'm aware of that has taken this

tack, but then we don't hear about cases that are settled or those that are

tried to a jury and not appealed. We only know about cases that are taken up

on appeal and have opinions published. Trial cases are almost never

published. Sometimes a judge will make a what he thinks is a significant ruling

on

evidence or a point of law in a case and request that the case publishers

publish

his opinion, but that's a very unusual occurrence.

Best,

GG

In a message dated 6/2/2003 5:28:41 PM Central Daylight Time,

ed.strout@... writes:

>

> Is it your belief (or experience, opinion, or whatever best describes your

> answer) that the " liability should also be with the medical director if the

> policy is found wanting, simply because it is the medical director who is

> the licensed practitioner " would hold true if the medical director wanted to

> carry the drug but the people with the money declined it? Also, as I

> mentioned earlier, changes to our SOCs are first approved by the local

> medical community. What if they didn't approve? What's your take on a

> scenario with these variables added?

>

> Ed Strout, RN, CEN, LP

> Clinical Practice Coordinator

> Austin- County EMS

> 517 S. Pleasant Valley Rd.

> Austin, Tx. 78741

> Office

> Pager

> Fax

> e-mail: ed.strout@...

>

>

[Guest guest]

,

Please review recent posts. Your point has been discussed. I pointed out

that it's been my experience that juries are negatively impressed by economic

arguments against carrying a certain item, particularly when one compares the

cost/benefit of AEDs with the cost/benefit of a cheap drug.

In my mind the question is going to come down to this: OK, docs and

managers, you think that this drug is unlikely to be needed, so you decided not

to

carry it. On the other hand, the evidence shows that it WAS in fact needed,

that its need could have been foreseen by a reasonable practitioner, and failure

to carry it is negligent.

Counterpoint to that: Uncontrollable PPH is very rare, and we could list at

least 100 other conditions that MIGHT occur. Since we can't carry EVERY drug

we choose to carry only those that we feel there is a reasonable chance of

using. And there are some genuine risks to using these drugs in the field which

we chose not to take a chance on.

Then I suspect the argument would go to morbidity/mortality studies, perhaps

using info from CDC and other data gathering agencies. Who will the jury

believe? Whoever makes the best argument.

Gene

[Guest guest]

,

I believe I hit on that earlier.

Schadone, NREMT-Paramedic

City of Austin

Austin/ County EMS

Medic 12 / Medic 24

@...

Re: Today's Challenge: OB/GYN Scenario

Mike, Ed and Gene,

Have ya'll considered the fact that the reason drug XYZ is not carried

on

the ambulance is a financial one. While the MD might have recommended

that

XYZ be carried and used by his/her paramedics, the director (the one

responsible for the budget) says no way, can't afford it.

Would the MD still by held responsible or would the Director be held?

This

does happend, especially to those of us working for the 3rd service

municipality. The budget has the final say as to what a system can do.

Just adding fuel to the fire..

RE: Today's Challenge: OB/GYN Scenario

>

> Ed,

>

>

>

> When I had stated that once you viewed the crew to be not negligent,

> then you must look at the service, the medical director, the local,

> State, and Nat'l Standards. I wasn't implying that they would be held

> liable, but the plaintiff's attorney might " get an education " in how

> things are done. We don't carry pitocin on our trucks, as you know,

but

> I would never hold Doc Racht, A/TCEMS, the City of Austin, TDH, NHTSA,

> or the US DOT liable for it. If it makes sense to carry it, then I

> trust that we would. Not everyone is so trusting, though and may need

> to look into why actual decisions were made before clearing them from

> suspicion.

>

>

>

> Just clarifying..

>

> Schadone, NREMT-Paramedic

> City of Austin

> Austin/ County EMS

> Medic 12 / Medic 24

> @...

>

>

>

>

>

>

>

>

>

[Guest guest]

,

I believe I hit on that earlier.

Schadone, NREMT-Paramedic

City of Austin

Austin/ County EMS

Medic 12 / Medic 24

@...

Re: Today's Challenge: OB/GYN Scenario

Mike, Ed and Gene,

Have ya'll considered the fact that the reason drug XYZ is not carried

on

the ambulance is a financial one. While the MD might have recommended

that

XYZ be carried and used by his/her paramedics, the director (the one

responsible for the budget) says no way, can't afford it.

Would the MD still by held responsible or would the Director be held?

This

does happend, especially to those of us working for the 3rd service

municipality. The budget has the final say as to what a system can do.

Just adding fuel to the fire..

RE: Today's Challenge: OB/GYN Scenario

>

> Ed,

>

>

>

> When I had stated that once you viewed the crew to be not negligent,

> then you must look at the service, the medical director, the local,

> State, and Nat'l Standards. I wasn't implying that they would be held

> liable, but the plaintiff's attorney might " get an education " in how

> things are done. We don't carry pitocin on our trucks, as you know,

but

> I would never hold Doc Racht, A/TCEMS, the City of Austin, TDH, NHTSA,

> or the US DOT liable for it. If it makes sense to carry it, then I

> trust that we would. Not everyone is so trusting, though and may need

> to look into why actual decisions were made before clearing them from

> suspicion.

>

>

>

> Just clarifying..

>

> Schadone, NREMT-Paramedic

> City of Austin

> Austin/ County EMS

> Medic 12 / Medic 24

> @...

>

>

>

>

>

>

>

>

>

[Guest guest]

Wiseman wrote:

>

> Have ya'll considered the fact that the reason drug XYZ is not carried on

> the ambulance is a financial one. While the MD might have recommended that

> XYZ be carried and used by his/her paramedics, the director (the one

> responsible for the budget) says no way, can't afford it.

Gene's " best salesman wins " conclusion is indeed the bottom line. But

next to that, the bottom line is the same here as within any scenario in

medicine; documentation is paramount. And I would hope that the

evaluative process which resulted in the approval or disapproval of drug

xyz was well documented by all concerned. If a good attorney, with good

experts is determined to make somebody pay for this incident, they

certainly have a good chance of doing so.

If carrying Pit was rejected by the medical director after request or

recommendation from the field, clinical coordinator, or others in the

medical community, he had better have a better excuse to present to the

court than, " I didn't think we would encounter PPH enough to bother with

it. " Both of those would hang him out to dry.

If carrying Pit was rejected by a clinical coordinator on a similar

basis, without submitting the matter to the MD, or even after MD

approval, he too had better have the significant documentation necessary

to trump the MD's education and experience, or else fall on his sword.

If carrying Pit was rejected by management or bean counters on the basis

of cost, they had best be prepared for the plaintiffs attorney to bend

them over in court as they show the jury how much was spent on the

office staff's coffee service in the last year.

And, of course, if any of the above persons plan to defend the rejection

of the very thing that could have saved this young mother's life with

the theory that, " Pitocin is just too dangerous for non-physicians to be

using, " they better have the documentation of published scientifc

studies backing that assertion up, or they are history.

Rob

[Guest guest]

Wiseman wrote:

>

> Have ya'll considered the fact that the reason drug XYZ is not carried on

> the ambulance is a financial one. While the MD might have recommended that

> XYZ be carried and used by his/her paramedics, the director (the one

> responsible for the budget) says no way, can't afford it.

Gene's " best salesman wins " conclusion is indeed the bottom line. But

next to that, the bottom line is the same here as within any scenario in

medicine; documentation is paramount. And I would hope that the

evaluative process which resulted in the approval or disapproval of drug

xyz was well documented by all concerned. If a good attorney, with good

experts is determined to make somebody pay for this incident, they

certainly have a good chance of doing so.

If carrying Pit was rejected by the medical director after request or

recommendation from the field, clinical coordinator, or others in the

medical community, he had better have a better excuse to present to the

court than, " I didn't think we would encounter PPH enough to bother with

it. " Both of those would hang him out to dry.

If carrying Pit was rejected by a clinical coordinator on a similar

basis, without submitting the matter to the MD, or even after MD

approval, he too had better have the significant documentation necessary

to trump the MD's education and experience, or else fall on his sword.

If carrying Pit was rejected by management or bean counters on the basis

of cost, they had best be prepared for the plaintiffs attorney to bend

them over in court as they show the jury how much was spent on the

office staff's coffee service in the last year.

And, of course, if any of the above persons plan to defend the rejection

of the very thing that could have saved this young mother's life with

the theory that, " Pitocin is just too dangerous for non-physicians to be

using, " they better have the documentation of published scientifc

studies backing that assertion up, or they are history.

Rob

[Guest guest]

Sorry guys,

I guess I was too late for this discussion...carry on.

RE: Today's Challenge: OB/GYN Scenario

> >

> > Ed,

> >

> >

> >

> > When I had stated that once you viewed the crew to be not negligent,

> > then you must look at the service, the medical director, the local,

> > State, and Nat'l Standards. I wasn't implying that they would be held

> > liable, but the plaintiff's attorney might " get an education " in how

> > things are done. We don't carry pitocin on our trucks, as you know,

> but

> > I would never hold Doc Racht, A/TCEMS, the City of Austin, TDH, NHTSA,

> > or the US DOT liable for it. If it makes sense to carry it, then I

> > trust that we would. Not everyone is so trusting, though and may need

> > to look into why actual decisions were made before clearing them from

> > suspicion.

> >

> >

> >

> > Just clarifying..

> >

> > Schadone, NREMT-Paramedic

> > City of Austin

> > Austin/ County EMS

> > Medic 12 / Medic 24

> > @...

> >

> >

> >

> >

> >

> >

> >

> >

> >

[Guest guest]

Sorry guys,

I guess I was too late for this discussion...carry on.

RE: Today's Challenge: OB/GYN Scenario

> >

> > Ed,

> >

> >

> >

> > When I had stated that once you viewed the crew to be not negligent,

> > then you must look at the service, the medical director, the local,

> > State, and Nat'l Standards. I wasn't implying that they would be held

> > liable, but the plaintiff's attorney might " get an education " in how

> > things are done. We don't carry pitocin on our trucks, as you know,

> but

> > I would never hold Doc Racht, A/TCEMS, the City of Austin, TDH, NHTSA,

> > or the US DOT liable for it. If it makes sense to carry it, then I

> > trust that we would. Not everyone is so trusting, though and may need

> > to look into why actual decisions were made before clearing them from

> > suspicion.

> >

> >

> >

> > Just clarifying..

> >

> > Schadone, NREMT-Paramedic

> > City of Austin

> > Austin/ County EMS

> > Medic 12 / Medic 24

> > @...

> >

> >

> >

> >

> >

> >

> >

> >

> >

[Guest guest]

Bernie,

From my understanding, in most medical cases, the " community " standard

of care is the national standard. Gene and others may correct my

understanding, though.

-Wes Ogilvie

[Guest guest]

" Socratic " ....I would never have come up with that. You are truly a learned

man. Now if you could just keep folks from getting their Socratic confused

with their sarcastic, the world would be a much nicer place. These law

things make my head hurt.

Ed Strout, RN, CEN, LP

Clinical Practice Coordinator

Austin- County EMS

517 S. Pleasant Valley Rd.

Austin, Tx. 78741

Office

Pager

Fax

e-mail: ed.strout@...

Re: Today's Challenge: OB/GYN Scenario

Ed,

I wouldn't describe what I write as belief, experience, or opinion. What I

write here is based upon a sort of Socratic method designed to elicit the

thoughts of others. I frankly don't know the answer to your question.

Here's what

I can add to your thoughts.

If the medical director were sued along with the service and it was his

position that he had recommended carrying the drug but management had

refused, then

he has a conflict in defense between himself and his employer. He could

then

file what is known as a " cross action " against his employer alleging that he

was effectively prevented by them from doing due diligence and practicing

standard of care because they refused to purchase and carry the drug. He

would

say that if he's liable, then they're liable for making him liable, and that

they therefore should stand for the judgment, not him. If the jury heard

evidence on that point, and there were sufficient records in the form of

memos, et

cetera, to back him up, then the jury might very well exonerate him and hold

the

service and its managers liable.

This brings up another point. In a lawsuit it's every person for

him/herself. It doesn't take long for alliances to disappear when judgment

liability is

lurking.

So far there hasn't been any litigation that I'm aware of that has taken

this

tack, but then we don't hear about cases that are settled or those that are

tried to a jury and not appealed. We only know about cases that are taken

up

on appeal and have opinions published. Trial cases are almost never

published. Sometimes a judge will make a what he thinks is a significant

ruling on

evidence or a point of law in a case and request that the case publishers

publish

his opinion, but that's a very unusual occurrence.

Best,

GG

In a message dated 6/2/2003 5:28:41 PM Central Daylight Time,

ed.strout@... writes:

>

> Is it your belief (or experience, opinion, or whatever best describes your

> answer) that the " liability should also be with the medical director if

the

> policy is found wanting, simply because it is the medical director who is

> the licensed practitioner " would hold true if the medical director wanted

to

> carry the drug but the people with the money declined it? Also, as I

> mentioned earlier, changes to our SOCs are first approved by the local

> medical community. What if they didn't approve? What's your take on a

> scenario with these variables added?

>

> Ed Strout, RN, CEN, LP

> Clinical Practice Coordinator

> Austin- County EMS

> 517 S. Pleasant Valley Rd.

> Austin, Tx. 78741

> Office

> Pager

> Fax

> e-mail: ed.strout@...

>

>

[Guest guest]

Gene,

I am behind on reading my mail, but I wanted to throw out a guess. I asked a

similar question to TDH a while back and waited almost two months for the

answer.

I believe the crew followed their standard of care and therefore could not be

held liable for any damages.

The attorney would have to do some really good research to see if the medical

director had recommended carrying either of the two drugs. If that were the

case, I believe the service would stand a good chance of being successfully

sued.

I often wonder if a medical director can be sued for not meeting the " standard

of care " with the protocols he provides for a service. Who defines standard of

care? Is this done at a national, state or local level? When a company that I

worked for in recent years opened a walk-in clinic we were advised by our

attorneys not to put a crash cart in the building because the other two clinics

did not use them. We would be exceeding the standard of care in our area.

You have seen several great responses. Let us know what you think. I do not do

well with suspense.

[Guest guest]

What is the " standard of care " in EMS?

1. The curriculum?

2. The books?

3. The prevailing practice?

Pitocin is not in the DOT. Thus, programs that provide education on pitocin

are exceeding the DOT. It is fine for a medical director (in this state) to

include the drug in protocols. In many states (such as California), that

would not be possible. But, the generally considered " standards " for EMS

practices (the books and the curriculum) do not list the drug within the

scope of practice. Thus, I don't think a litigant could prove that failure

to carry pitocin failed to meet the standard of care (except maybe the OJ

jury).

E. Bledsoe, DO, FACEP

Midlothian, Texas

Re: Today's Challenge: OB/GYN Scenario

Gene,

I am behind on reading my mail, but I wanted to throw out a guess. I asked a

similar question to TDH a while back and waited almost two months for the

answer.

I believe the crew followed their standard of care and therefore could not

be held liable for any damages.

The attorney would have to do some really good research to see if the

medical director had recommended carrying either of the two drugs. If that

were the case, I believe the service would stand a good chance of being

successfully sued.

I often wonder if a medical director can be sued for not meeting the

" standard of care " with the protocols he provides for a service. Who defines

standard of care? Is this done at a national, state or local level? When a

company that I worked for in recent years opened a walk-in clinic we were

advised by our attorneys not to put a crash cart in the building because the

other two clinics did not use them. We would be exceeding the standard of

care in our area.

You have seen several great responses. Let us know what you think. I do not

do well with suspense.

[Guest guest]

,

Could an attorney argue that carrying Pitocin is the " standard of care "

for that region. I know I was taught, by you as a matter of fact, about

Pitocin in 1981. Does that not set a standard of practice here in DFW

area. Could this argument be used and would it be successful? Maybe some

our legal eagles have an answer to that question.

Bernie Stafford EMTP

>>> bbledsoe@... 6/3/03 10:56:04 AM >>>

What is the " standard of care " in EMS?

1. The curriculum?

2. The books?

3. The prevailing practice?

Pitocin is not in the DOT. Thus, programs that provide education on

pitocin

are exceeding the DOT. It is fine for a medical director (in this

state) to

include the drug in protocols. In many states (such as California),

that

would not be possible. But, the generally considered " standards " for

EMS

practices (the books and the curriculum) do not list the drug within

the

scope of practice. Thus, I don't think a litigant could prove that

failure

to carry pitocin failed to meet the standard of care (except maybe the

OJ

jury).

E. Bledsoe, DO, FACEP

Midlothian, Texas

Re: Today's Challenge: OB/GYN Scenario

Gene,

I am behind on reading my mail, but I wanted to throw out a guess. I

asked a

similar question to TDH a while back and waited almost two months for

the

answer.

I believe the crew followed their standard of care and therefore could

not

be held liable for any damages.

The attorney would have to do some really good research to see if the

medical director had recommended carrying either of the two drugs. If

that

were the case, I believe the service would stand a good chance of

being

successfully sued.

I often wonder if a medical director can be sued for not meeting the

" standard of care " with the protocols he provides for a service. Who

defines

standard of care? Is this done at a national, state or local level?

When a

company that I worked for in recent years opened a walk-in clinic we

were

advised by our attorneys not to put a crash cart in the building

because the

other two clinics did not use them. We would be exceeding the standard

of

care in our area.

You have seen several great responses. Let us know what you think. I do

not

do well with suspense.

[Guest guest]

Neil,

I believe that the ¡ÈStandard¡É has to be appreciated from the

Nat¡Çl,

State and local levels.

If everyone in the country carries epinephrine and you don¡Çt, well you

are falling outside the standard. If Texas is the only state where you

see amiodorone, but Bluckmuckville, TX EMS doesn¡Çt carry it, then they

are outside the standard. Then, if Bluckmuckville EMS decides to carry

Cure-It-All and one truck in Bluckmuckville doesn¡Çt have it stocked,

then that truck is outside of the standard.

I think if 51% of any given group utilizes it, then it can be argued to

be standard.

Schadone, NREMT-Paramedic

City of Austin

Austin/ County EMS

Medic 12 / Medic 24

@...

Re: Today's Challenge: OB/GYN Scenario

Gene,

I am behind on reading my mail, but I wanted to throw out a guess. I

asked a similar question to TDH a while back and waited almost two

months for the answer.

I believe the crew followed their standard of care and therefore could

not be held liable for any damages.

The attorney would have to do some really good research to see if the

medical director had recommended carrying either of the two drugs. If

that were the case, I believe the service would stand a good chance of

being successfully sued.

I often wonder if a medical director can be sued for not meeting the

" standard of care " with the protocols he provides for a service. Who

defines standard of care? Is this done at a national, state or local

level? When a company that I worked for in recent years opened a walk-in

clinic we were advised by our attorneys not to put a crash cart in the

building because the other two clinics did not use them. We would be

exceeding the standard of care in our area.

You have seen several great responses. Let us know what you think. I do

not do well with suspense.

[Guest guest]

Is it not true that sometimes (very occasionally) the books and the

curriculum fall behind certain prevailing practices? I agree that most

standards follow the curriculum which is set forth in the current texts,

though. Also, aren¡Çt we held to a standard of what a reasonable person

with similar training would do in a similar set of circumstances?

Schadone, NREMT-Paramedic

City of Austin

Austin/ County EMS

Medic 12 / Medic 24

@...

Re: Today's Challenge: OB/GYN Scenario

Gene,

I am behind on reading my mail, but I wanted to throw out a guess. I

asked a

similar question to TDH a while back and waited almost two months for

the

answer.

I believe the crew followed their standard of care and therefore could

not

be held liable for any damages.

The attorney would have to do some really good research to see if the

medical director had recommended carrying either of the two drugs. If

that

were the case, I believe the service would stand a good chance of being

successfully sued.

I often wonder if a medical director can be sued for not meeting the

" standard of care " with the protocols he provides for a service. Who

defines

standard of care? Is this done at a national, state or local level? When

a

company that I worked for in recent years opened a walk-in clinic we

were

advised by our attorneys not to put a crash cart in the building because

the

other two clinics did not use them. We would be exceeding the standard

of

care in our area.

You have seen several great responses. Let us know what you think. I do

not

do well with suspense.

[Guest guest]

In a message dated 6/3/2003 10:46:49 AM Central Daylight Time,

drdugud@... writes:

>

> Gene,

>

> I am behind on reading my mail, but I wanted to throw out a guess. I asked a

> similar question to TDH a while back and waited almost two months for the

> answer.

>

> I believe the crew followed their standard of care and therefore could not

> be held liable for any damages.

>

GG: I agree. The medics had no control over the drugs they carried and the

protocols that were provided for them.

> The attorney would have to do some really good research to see if the

> medical director had recommended carrying either of the two drugs. If that

were

> the case, I believe the service would stand a good chance of being

successfully

> sued.

GG: Attorneys do that by first getting all the records they can pry loose.

Then they take everybody's deposition and ask them under oath whether or not

the medical director had ever recommended carrying either drug. They can send

investigators around to talk to employees and seek information. Many

investigators employed by attorneys are former FBI agents and are very adept at

getting people to talk. Investigators seek information about the identities of

recently fired employees, disgruntled employees, anybody who knows something.

They are usually much better prepared than defense witnesses are. If there was

ever an issue about carrying a drug, they'll find out about it.

>

> I often wonder if a medical director can be sued for not meeting the

> " standard of care " with the protocols he provides for a service. Who defines

> standard of care? Is this done at a national, state or local level?

GG: Standard of care is proven through the testimony of qualified expert

witnesses. In most areas of medicine today there is a national, if not a

global,

standard of care. For example, in the OB case I presented, the standard

should be the same in Boise as in Bangor, Maine. It is probably the same in

Delhi, India. Evidence of standard of care may also involve medical texts,

medical encyclopedias, medical journal articles, and in the case of EMS, the

National Standard Curriculum.

Doctors tell me all the time that there is no national standard of care. If

they testify to that opinion they will generally be closely examined on the

basis for their opinions. They will be asked about each and every textbook's

content and even asked about the curriculum that was covered during their

medical education and residency. They will be asked just how it is that they

have

reached a different opinion from that of recognized experts in the field. They

will be asked what independent research studies they have conducted on the

subject, what journals they have been published in, what texts they have

written, what committees in their certifying organization they serve on, what

committees they are on at their hospital, and so forth and so on. Other

physicians from the same community may be called to contradict them.

Often the case ends up being a battle of experts, with the most impressive

one winning. Most plaintiffs' lawyers like to use medical school professors

whenever possible. It is difficult for a doctor to overcome the expert

testimony

of a published, peer reviewed, medical school professor.

Also, lots of doctors make terrible witnesses. They come to court with an

attitude, it shows, and the jury ends up hating them. The professional expert

witness, on the other hand, knows exactly how to testify. He or she is never

nonplused or caught by surprise, engages the jury in a dialog that makes each

of the jurors think he's talking just to them, patiently explains his

positions, knows how to handle being asked difficult and pointed questions by

the

other side, is generally charming and likable. This witness understands that

his role is to sell the jury on his theory, and he will be well prepared to do

so. He probably has testified on the same points many times before, whereas

the physician defendant has little or not prior experience in court. The

plaintiff's attorney will play this for all it's worth. The defense attorney

will

of course adopt the same tactics with the plaintiff's expert. But the

plaintiff's expert is quite apt to be a much better witness than the defendant.

I know of no cases where an EMS medical director has been successfully sued,

but I would not be surprised if some haven't been sued.

When a company that I worked for in recent years opened a walk-in clinic we

were

> advised by our attorneys not to put a crash cart in the building because

> the other two clinics did not use them. We would be exceeding the standard of

> care in our area.

>

GG: I find that to be dumber than dumb. The standard of care is a national

standard of care, and when there are AEDs all over the place for lay people to

use, AEDs in police cars, in airports, in libraries and in casinos, it

would be hard to convince a jury that it's not reasonable to have ACLS available

in a clinic. GG.

> You have seen several great responses. Let us know what you think. I do not

> do well with suspense.

>

>

[Guest guest]

,

Oxytocin IS in fact in the DOT 1998 National Standard Curriculum for

Paramedics. It's in part 5.14, which is Medical/Obstetrics. Here's the

pertinent

language:

Maternal complications of labor and delivery

1. Postpartum hemorrhage

a. Incidence

(1) Loss of more than 500 ccs of blood immediately following

delivery

(2) May be caused by

(a) Lack of uterine tone

( Vaginal or cervical tears

© Retained pieces of the placenta

(d) Clotting disorders

b. Assessment

(1) History to include

(a) Large infant

( Multiple births have occurred

© The patient has had placenta previa

(d) The patient has had abruptio placenta

(e) The patient has had prolonged labor

(2) Physical examination

(a) Treat the patient The paramedic must rely on the

patient's clinical appearance and vital signs

( The uterus feels soft on palpation

© Inspect the external genitalia for injury resulting

in excessive bleeding

(d) Observe signs and symptoms of hypovolemic shock

c. Management

(1) ABCs

(2) High flow, high concentration oxygen

(3) Place the infant at the mother's breast if just delivered

(4) Provide uterine massage

(5) Consider 2 large-bore IVs for volume replacement

(6) Administer oxytocin per physician's order

(a) Indications

i) To stimulate immediate postpartum contraction of

the uterus and to control postpartum uterine bleeding, especially if uterine

massage is ineffective or the patient is in shock

( Administration - injectable oxytocin contains 10 USP

units (20mg) per milliliter

i) IV dosage

a) Ten to twenty USP units in 1000 ccs

crystalloid (normal saline)

Flow rate of 100-125 cc/hr., titrated to the

severity of hemorrhage and uterine response

ii) IM dosage

a) Ten USP units (1 ml) IM

Only if unable to start an IV

(7) Do not attempt to force delivery of the placenta

(8) Do not pack the vagina

(9) Emergent transport of the patient

Best,

GG

In a message dated 6/3/2003 10:58:19 AM Central Daylight Time,

bbledsoe@... writes:

> Subj: RE: Today's Challenge: OB/GYN Scenario

> Date: 6/3/2003 10:58:19 AM Central Daylight Time

> From: <A HREF= " mailto:bbledsoe@... " >bbledsoe@...</A>

> Reply-to: <A

HREF= " mailto: " > </A>

> To: <A

HREF= " mailto: " > </A>

> Sent from the Internet

>

>

>

> What is the " standard of care " in EMS?

> 1. The curriculum?

> 2. The books?

> 3. The prevailing practice?

>

> Pitocin is not in the DOT. Thus, programs that provide education on pitocin

> are exceeding the DOT. It is fine for a medical director (in this state) to

> include the drug in protocols. In many states (such as California), that

> would not be possible. But, the generally considered " standards " for EMS

> practices (the books and the curriculum) do not list the drug within the

> scope of practice. Thus, I don't think a litigant could prove that failure

> to carry pitocin failed to meet the standard of care (except maybe the OJ

> jury).

>

> E. Bledsoe, DO, FACEP

> Midlothian, Texas

>

>

> Re: Today's Challenge: OB/GYN Scenario

>

> Gene,

>

> I am behind on reading my mail, but I wanted to throw out a guess. I asked a

> similar question to TDH a while back and waited almost two months for the

> answer.

>

> I believe the crew followed their standard of care and therefore could not

> be held liable for any damages.

>

> The attorney would have to do some really good research to see if the

> medical director had recommended carrying either of the two drugs. If that

> were the case, I believe the service would stand a good chance of being

> successfully sued.

>

> I often wonder if a medical director can be sued for not meeting the

> " standard of care " with the protocols he provides for a service. Who defines

> standard of care? Is this done at a national, state or local level? When a

> company that I worked for in recent years opened a walk-in clinic we were

> advised by our attorneys not to put a crash cart in the building because the

> other two clinics did not use them. We would be exceeding the standard of

> care in our area.

>

> You have seen several great responses. Let us know what you think. I do not

> do well with suspense.

>

>

[Guest guest]

I stand corrected. Thanks.

E. Bledsoe, DO, FACEP

Midlothian, Texas

Re: Today's Challenge: OB/GYN Scenario

>

> Gene,

>

> I am behind on reading my mail, but I wanted to throw out a guess. I asked

a

> similar question to TDH a while back and waited almost two months for the

> answer.

>

> I believe the crew followed their standard of care and therefore could not

> be held liable for any damages.

>

> The attorney would have to do some really good research to see if the

> medical director had recommended carrying either of the two drugs. If that

> were the case, I believe the service would stand a good chance of being

> successfully sued.

>

> I often wonder if a medical director can be sued for not meeting the

> " standard of care " with the protocols he provides for a service. Who

defines

> standard of care? Is this done at a national, state or local level? When a

> company that I worked for in recent years opened a walk-in clinic we were

> advised by our attorneys not to put a crash cart in the building because

the

> other two clinics did not use them. We would be exceeding the standard of

> care in our area.

>

> You have seen several great responses. Let us know what you think. I do

not

> do well with suspense.

>

>