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From the June 2010 Issue | Tuesday, June 1, 2010


Honoring EMS Visionaries
Pioneers of Paramedicine event recognizes four industry leaders 
On May 8, four influential physicians were honored at the Pioneers of Paramedicine Lifetime Achievement Awards Gala, hosted by the County of Los Angeles Fire Museum at the historic Millennium Biltmore Hotel in Los Angeles.

The event began with a welcome by Randolph Mantooth, star of Emergency!, and Baxter Larmon, director of the Center for Prehospital Care at UCLA. The two also introduced the other members of the event’s planning committee: Nancy McFarland, Kristen Connors and Joe Covelli. It honored Leonard Cobb, MD; J. Michael Criley, MD; Walter Graf, MD; and Eugene Nagel, MD.

Leonard Cobb, MD, was founding medical director of Seattle’s Medic One Program and served in that role for nearly 25 years. Cobb noted that physicians helped staff Medic One units in the first 18 months of the Seattle program but soon realized that the firefighters trained as paramedics could ably handle all the ALS tasks assigned to them without a physician at their side. He received full support from Seattle Fire Chief Gordon Vickery. Cobb credited that and the implementation of an abbreviated, community-wide citizen CPR program with the outstanding results soon realized in out-of-hospital resuscitations.

J. Michael Criley, MD, founded the Los Angeles County Paramedic Program in 1969, and the Los Angeles County Paramedic Training Institute is named in his honor. He has been on the full-time faculty at Harbor-UCLA Medical Center for 42 years and is emeritus professor of medicine and radiological sciences at the UCLA School of Medicine. The initial program Criley conducted at Harbor General Hospital consisted of 18 firefighters, 12 from the Los Angeles County Fire Department and six from Los Angeles City Fire Department.

Walter Graf, MD, launched a Mobile Coronary Care Unit in 1969—a fully equipped vehicle staffed by nurses who were empowered to start IV infusions, administer drugs and defibrillate. Established by Daniel Freeman Hospital in 1970 as one of the first paramedic training programs in the nation, the program joined forces with the UCLA Center for Prehospital Care in 1999. Under Graf’s leadership, the Daniel Freeman program became the first nationally accredited paramedic education program in the country.

Eugene (Gene) Nagel, MD, helped craft the Miami Fire Department’s paramedic program. Nagel said that with strategically located resources and rapid response times, the Miami crews were poised to take on the demands of EMS. Nagel developed the first telemetry unit in the U.S. in his garage and, in March 1967, Miami’s new “paramedics” began to routinely transmit ECGs to Jackson Memorial Hospital using combined radio/telemetry units that weighed in at 54 pounds but were battery-powered and “portable.”

The County of Los Angeles Fire Museum will produce the interviews conducted with the honorees and announce the premiere of the Pioneers of Paramedicine film when it’s finalized.—A.J. Heightman, MPA, EMT-P

A Picture Worth 1,000 Woes
In an effort to protect EMS patients’ privacy, a New Jersey assemblywoman introduced legislation making it a fourth-degree crime for first responders to take and post photos or videos of patients without consent. A fourth-degree crime carries a fine of up to $10,000, a prison term of up to 18 months or both.

Assemblywoman Nancy F. Munoz’s office says the impetus for bill A2274 was a complaint from a victim’s family that a volunteer EMT tried to show them on-scene photographs of the woman, who later died.

The bill underscores the lack of—and need for—photo policies in EMS agencies.
Ray Kemp, a professional EMS, rescue and police photographer, says there are legitimate reasons for on-scene photography: The photos can be valuable teaching tools and used to familiarize hospital staff with the incident factors. However, problems arise when the photos make their way outside the educational field. Once a photo is e-mailed, there’s no way to know where it will go from there.

In his work with fire departments and EMS agencies, Kemp has found he knows more about the need for policies and procedures to protect patients than his clients. In the world of social media and omnipresent cell phones with built-in cameras, any agency without a well written, clearly defined scene photography policy is ripe for legal problems.

“We advocate that EMS agencies have policies making it clear that pictures should—if at all—be taken only where there is a legitimate patient care or operational need and only on devices owned and issued by the organization,” says Doug Wolfberg, of the EMS law firm Page, Wolfberg and Wirth. “And the organization must own all images and control them in the same way they would a written patient care report. Photos must never be taken or copied onto any personal cell phone or other imaging device.”

Kemp has written articles for JEMS about EMS photography guidelines, including the July 2009 article “At the Touch of a Button” (read it at jems.com/magazines). Page, Wolfberg and Wirth have a sample policy: “Use of Cell Phones, PDAs and Imaging Devices under EMS Law Library, Sample Forms and Policies” on their Web site, www.pwwemslaw.com.
—Ann-Marie Lindstrom

Quick Take
Important Hydrogen Sulfide Gas Warning

Two recent chemical suicides should cause EMS agencies to alert their crews to be more vigilant during suspicious or questionable history calls. In February, a 23-year-old man in St. Petersburg, Fla., committed chemical suicide, and a second incident involving hydrogen sulfide gas has made headlines. On April 15, an Indiana University student intentionally died after barricading himself in his dorm room with a bucket of chemicals.

In both cases, the responding crews were spared toxic involvement because the victims placed signs warning responders of the dangerous material (“Stay Away” and “Contact Haz-Mat” were posted in the vehicle involved in the first, and “Warning H2S” in the second).

However, crews responding to similar suicides in the future may not be as fortunate. According to the National Association of State EMS Officials’ March “Washington Update,” this type of suicide is gaining prevalence because of “ad hoc” Web sites posting information on how to mix household chemicals to create the deadly gas.
Following the Florida incident, DHS’s Emergency Management and Response Information Sharing and Analysis Center released a bulletin warning responders about the dangers associated with this type of chemical.

Among the advice listed: Be aware of the potential for the presence of poisonous gas when approaching an unresponsive patient in a confined space; remember that hydrogen sulfide has a strong, rotten-egg-like odor; and know that the patient’s clothes will continue to release the gas for some time.

Read the bulletin at usfa.dhs.gov/fireservice/subjects/emr-isac/infograms/ig2010/8-10.shtm and the “Washington Update” at www.nasemso.org/NewsAndPublications/TheWashingtonUpdate/documents/WU032310.pdf.

Pro Bono Transfer-of-Care  Liability
A recent $10 million jury verdict against a highly respected ambulance service has drawn attention to liability in interfacility transfer-of-care situations. The agency was found negligent when an infant—delivered prematurely in the ambulance while en route to another hospital—developed cerebral palsy secondary to hypoxia.
Who is liable when interfacility transfers go bad? Contrary to popular belief, liability doesn’t simply “stop” for one party and automatically “fall” on another when care is transferred. The sending facility can be liable under multiple legal theories, including the federal Emergency Medical Treatment and Active Labor Act (EMTALA), if the patient is unstable when transferred, if the appropriate transfer paperwork isn’t present or if the sending facility doesn’t make adequate arrangements for the patient’s needs during transfer. The sending facility can also be liable under common law negligence theories if it fails to uphold applicable tort standards of care. '

Liability can also fall to the EMS agency and crew. Although EMTALA doesn’t apply to non-hospital-owned ambulances, negligence principles do apply. This means that the EMS agency and its personnel must uphold all applicable standards of care in their clinical and operational activities.

How can the EMS agency’s risks be reduced in these situations? Liability can’t be eliminated entirely, but a few strategies should be considered to properly manage it.
First, ensure your EMS personnel are specifically trained (e.g., through “critical care transport” courses) and your vehicles are appropriately equipped and maintained to handle the specific types of transports you encounter.

Second, adopt adequate policies and procedures and current, approved clinical protocols specific to the type of interfacility transports you provide (i.e., cardiac, neonatal, burn, etc.) and ensure continuous access to online medical control during interfacility transports.

Third, consider implementing contracts with the facilities you serve that require they send appropriate personnel where the needs of the patient exceed the capabilities of an EMS crew. Seek indemnification provisions in these contracts for added legal protection.

Fourth, work with your referring facilities to ensure they understand your agency’s capabilities and that they don’t simply call 9-1-1 and expect an immediate response that meets the needs of their patient in every case. In our view, calling 9-1-1 to arrange interfacility transports is an inappropriate abuse of the system.

Last—be sure to consult your own agency’s legal counsel. No provider or agency should accept the care of a patient whose needs or condition exceeds their training, capabilities or scope of practice. Although refusing to provide service may open its own Pandora’s box of legal issues, providers or agencies that get in over their heads are surely opening the door to significant liability.

Pro Bono is written by attorneys Doug Wolfberg and Steve Wirth of Page, Wolfberg & Wirth LLC, a national EMS-industry law firm. Visit the firm’s Web site at www.pwwemslaw.com for more EMS law information.
JEMS



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