EMS EduCast/EMS Garage #48 Quality - comments

In the comments to EMS EduCast/EMS Garage #48 Quality, commenting about Dr. Eisenberg's quote,[1] 30 ff/pm wrote -

"We've recorded virtually every cardiac arrest event, with not only the rhythm, but with the voice."

Great teaching tool but if an ambo chasing attorney gets hold of it, there could be some $$$ payed out even if no one did anything wrong.

My city attorney is great at throwing cash around just to avoid going to court.
The feeling is that the jury might be swayed by claims - even if they're not true and didn't really have anything to do with the outcome. Sucks and isn't right, but that's the world we live in.

Assuming that you are describing the activity of this city attorney accurately, the attorney appears to be encouraging law suits, rather than protecting the city or protecting the patients. If other lawyers realize that the lawyer representing the city is afraid to go to court, they will find any excuse to bring a suit.

As long as the city attorney will throw money at them to go away, what do they have to lose? A better question is, Why would the city hire someone like that?

The city managers hire somebody to provide a specialized service that they are not qualified to perform themselves, whether it is legal defense, or EMS, or something else. They trust these experts to provide them with competent services. It is possible that there were legitimate reasons to justify the lawyer settling in all of these cases, but even though I am not a lawyer, I would bet that it is more of a fear of going to court, than a valid claims on the parts of all of the plaintiffs. The city attorney probably does not understand a thing about EMS. Ignorance leads to fear. Fear leads to settlement out of court. Or whatever Yoda said about fear. It appears that the city attorney would rather pay out the city's money. Rather than demonstrate his/her profound ignorance of all things EMS.

If their approach to EMS is how do we avoid getting sued, rather than how do we improve patient care, it is a bit of a Catch-22 situation. They are discouraging attempts to improve quality of care, because anything they find out about how bad the quality actually is, could be used against them. Ignore it, pay out money now and then, here and there, but pretend that you cannot improve things, because some things are too dangerous to know?

Stay the same?

Avoid change?

Ignore problems?

There is only one way to stay the same in medicine. Only in death do things stop changing. Even then there are changes, but the person no longer has any reason to care.

How does one form of medical record create more liability than other forms? And an audio recording of the events is just that - another form of medical record. In some places, video recordings are used.

The city attorney appears to be looking at this only from the perspective of the harm it might do. In other words, the city attorney has absolutely no understanding of risk management. A recording may help the jury to understand what happened better than they would with a paramedic mumbling through the reading of a chart. Paramedics are not hired for their ability to read out loud. Paramedics are hired for their ability to treat patients on scene. A recording of the paramedic doing what he/she has actually been trained and hired to do. This might work for the defense much better than anything else the city attorney could present. Yet, the city attorney would probably prohibit this, because of ignorance - a level of comfort hiding behind ignorance that is scary.

I know what people are thinking - How do I know that is what the city attorney would do? I don't know it. I am speculating. Unfortunately, I believe that 30 ff/pm is correct in concluding that the city attorney would act this way. I have dealt with attorneys in hospitals, where I taught ACLS. In 2 of these hospitals, I was informed that the attorneys had instructed the hospital emergency response teams to never touch anyone, who does not exhibit evidence of being a patient. The emergency response teams are only called to suspected emergencies. If a family member of a patient experiences cardiac arrest, they are not to touch the family member of the patient until after the patient is registered.

No wrist band, no treatment. You get treated the same as if you were trying to sneak into a night club. Actually, the night club staff would probably provide CPR if your heart were to arrest.

The attorneys believe that the potential harm is greater than the benefit. Yet, these are the same people, the paramedics and emergency response teams, who will be treating the patient visitor after the patient is registered.

Is the emergency response team's care going to become better, just because the visitor has been registered?

No. Delaying CPR is possibly the worst thing they can do, but that is what the lawyers are insisting they do. The lawyers are making the medical decisions.

Is there any way the attorneys can claim that the unregistered patient is really not a patient?

No. According to EMTALA (the Emergency Medical Treatment and Active Labor Act), anyone presenting with a complaint within 250 yards of the hospital, or anywhere within the hospital, is automatically a patient. These patients may not be turned away, until after a medical screening and stabilizing treatment, even when being transferred to another hospital.

Cardiac arrest is one of the most time sensitive conditions. Delaying care is just as bad as refusing to deliver care, because there is a very limited time during which treatment is likely to be effective. Supposedly, the chance at resuscitation decreases 10% for every minute of delay in initiating treatment, or every minute of inadequate treatment. Such as an 80 year old Grandma performing compressions on her husband, while the emergency response team stands around digitally monitoring their own sphincter tone. Look Grandma, no prostatic hypertrophy!

While I am still not a lawyer, there is one word that comes to mind, when describing this approach - indefensible. OK, not just one word. There are plenty of adjectives that could go along with indefensible, but none of them are good.

A different approach might be to only hire competent personnel. I am not stating that the emergency response teams are not competent, or that the paramedic coworkers of 30 ff/pm are not competent. The problem is that the city attorney presumes that these medics are incompetent, or that more evidence would only work against the defense.

If the attorneys were comfortable with the competence of the paramedics and emergency response teams, then the attorneys should be much more confident that more facts will lead to a better defense, not the other way around. But they do not. If they are that uncomfortable with the employees, they either need to learn about what the employees do, demand higher standards, or find some other way to improve quality - such as using audio recordings of cardiac arrests. You know that I am in favor of both. Even if the standards are already high, make them higher. Quality is about improvement - never being satisfied. not in a 6 Sigma way, but in always looking for ways to improve patient care. Actively participating in research.

Dr. Eisenberg mentioned that some cities, that were studied, had ridiculously low resuscitation rates. The reaction, when the news was published? Apathy. nobody cared. Less than 1% successful resuscitation. While where Dr. Eisenberg works, the resuscitation rate is about 50%. This is not a minor difference, so how is it that people do not care? But, they don't care.

The other comment was from Greg Friese, one of the hosts of the EMS EduCast, where the broadcast with Dr. Eisenberg started. Greg's response to 30 ff/pm was -

I would rather defend a recording of the facts than speculate about facts based on the recollections of all involved.

Much more succinct than what I wrote. I completely agree. I think that 30 ff/pm also agrees, but his city attorney is the one, who does not agree.


^ 1 EMS Garage Special Edition: How to Improve Survival from Sudden Cardiac Arrest Episode 48
EMS Garage
Links to broadcast and downloads.

A cooperative broadcast between EMS Garage (above) and EMS EduCast (below):

How to Improve Survival from Sudden Cardiac Arrest: EMS Educast Episode 27


1 comment:

John Fekety, J.D., EMT-P said...

When I first read about San Diego using the Zoll monitors that allowed voice recording I wrote a warning regarding the use of voice recorders in emergency situations. Many states, including PA where I previously practiced law, prohibit audio recordings unless all parties to the recording know and agree that a recording is being made. Violation of that law can result in criminal charges. Obviously if it is just your crew and the deceased the recording is not an issue. However, just how often is that the case? Most times there are family members or other bystanders. Many times there are law enforcement personnel or other first responders. Under a particular state's law each of those persons would have to be told and agree to the audio recording. And just to clarify a point made in rebuttal to my warning, the audio recordings made when people call emergency dispatch centers have specific exemptions from recording and wiretapping laws so it is not the same issue. Although I personally have questions about the usefulness of this practice, if your service does choose to initiate audio recordings of calls, consult with an attorney knowledgeable about criminal and privacy laws before beginning such action.