Since 1985, 55 Disaster Medical Assistance Teams (DMATs) deployed by the National Disaster Medical System (NDMS) have been the nation_s primary responder to large-scale medical disasters. But recently some DMAT commanders claimed the U.S. Department of Health and Human Services (HHS) is systematically weakening the DMATs, which are self-contained, medical MASH-type units staffed by civilian medical personnel who become temporary, paid federal employees during disaster response.
HHS insists this isn_t the case. Their spokesman Bill Hall says the department remains ˙fully committedÓ to NDMS. ˙We are not closing down or eliminating teams. In fact, for fiscal 2009, HHS is proposing a $7 million increase for NDMS,Ó he says.
But David G.C. McCann, MD, chief medical officer of the FL-1 DMAT and chair of the American Board of Disaster Medicine says HHS is ˙marginalizing NDMS,Ó as it ramps up the new U.S. Public Health Service (PHS) Commissioned Corps teams of uniformed medical responders. He cites the following evidence:
> Only about 10% of the 55 DMATs are at Type I preparedness levels;
> Adherence to staffing requirements is no longer required (e.g., deployable teams no longer need three tiers of 35 members or 105 total members);
> Procedures for new applicants are extremely burdensome;
> A freeze on hiring new NDMS personnel from September 2005Ï2007 resulted in the loss of about 20% of personnel;
> The NDMS training contract was canceled, and there has been no formal online training for more than two years;
> Field training budgets have been severely cut or even eliminated;
> Warehouses for equipment are being canceled and caches moved to regional locations; and
> Caches aren_t being properly maintained and aren_t available for training, so team members often don_t even see the equipment until they need to use it.
˙We spent many years trying to solve problems to allow the DMATs to deploy earlier and earlier,Ó says CA-4 DMAT Commander Jake Jacoby, MD, an attending physician in emergency medicine at the University of California San Diego Medical Center and a former chair of the National Association of DMATs (NADMAT). ˙One solution was local caches and to get our own trucks. Team leaders know what works and what doesn_t during the first 72 hours, and we know that not having our medical equipment and supplies doesn_t work.Ó
According to Hall, HHS is closing some DMAT warehouses as ˙legacy leasesÓ end and ˙in a limited number of locations, they_re consolidating team caches.Ó He says HHS is moving someƒbut not allƒDMAT caches because they previously ˙were in places with only ground-transport capabilitiesÓ and the move will ˙bring some consistency to the caches.Ó
But Jacoby says, ˙This means we can_t deploy as a team, and [we] lose our ability to train with our equipment. We_re also losing our team meeting sites and team offices (so we have no place to keep records), and we no longer even have a phone number for our team. ... We learned the lessons from after-action reports and Âhot washes_ from deployments and solved the problems, but we now see these lessons totally ignored.Ó
Noting that Congress gave NDMS $44 million in fiscal 2007 and $47 million in 2008, McCann says, ˙What has not been explained to anyone in NDMS is why the extreme team-funding contraction is occurring despite an increased budget for NDMS from Congress.Ó For example, one Oregon DMAT saw its operational budget slashed from $150,000 in fiscal 2005 to $35,000 in 2008 and its training budget cut from $87,000 in 2005 to $8,700 in 2008.
The commanders of six Florida-based DMATs posted a letter online on Feb. 1 (atwww.nadmat.org/File/FLCommadersLetter.pdf) saying they had ˙confirmed through multiple independent sourcesÓ within the department that HHS officials are ˙engaged in a systematic plan to deemphasizeÓ NDMS and to replace DMATs with new PHS Commissioned Corps Health and Medical Response (HAMR) teams.
The 2006 PHSCommissioned Corps Transformation Implementation Plan states that HAMR teams will be the department_s ˙first asset in addressing deployment needs for national special security events, natural disasters, terrorist attacks, international humanimedically underserved populations.Ó
But Hall insists that the HAMR teams will play a ˙complementary roleÓ to DMATs. ˙Nobody is being replaced,Ó he stresses.
HHS has proposed $30 million in its fiscal 2009 budget for the PHS Commissioned Corps, stating in itsBudget in Brief: Fiscal Year 2009 document: ˙This effort will involve the establishment of two 105-member [HAMR] teams, which will provide a highly trained, quick response asset, ready to immediately deploy to emerging public-health situations and emergencies and develop a team-oriented deployment process.Ó
Although the 2008 HHS budget didn_t include HAMR funding, several DMAT team members insist HHS has already developed at least two HAMR teams, fueling their suspicions that DMAT funds may have been redirected for this purpose.
According to McCann, the DMATs ˙have a reputation for feistiness, and for being a thorn in the side in D.C. But the Commissioned Corps are always federal employees, so if they step out of line they can be fired.Ó
A DMAT team member, who asked to remain anonymous, said, ˙HAMR team [members] are less hassle because they_re uniformed, commissioned officers who can_t yell back, plus HHS can keep them in the Âtheater_ longer.Ó
The Florida DMAT commanders ask other NDMS team commanders to encourage elected officials to ˙save NDMS Ó using speaking points and/or a sample letter posted at www.nadmat.org.
˙Even if the intent is benign, they_re gutting the system,Ó McCann says. ˙They_re taking a good thing and ruining it.Ó
But Hall says, ˙There_s a lot of misinformation snowballing out there.Ó
˙The biggest frustration for us has been the lack of communication,Ó says Churton Budd, RN, EMT-P, deputy commander of OH-1 DMAT inToledo,Ohio. ˙If we understood the big picture and felt confident it could work, we could give our support, but we feel like were having the rug pulled out from under us without knowing why or when to expect it to be pulled.Ó
More information from HHS, Budd says, would allow DMAT members to ˙roll with the punches and remain ÂSemper Gumby_Óƒa DMAT phrase, he explains, as meaning ˙We remain flexible but with rigid adherence to good patient care.Ó
EMS Stroke-System Guidelines Issued by AHA
The discovery that timely thrombolytics (or ˙clot bustersÓ) can improve outcomes for many stroke patients has prompted some communities and regions to create prehospital systems (similar to STEMI networks for patients suffering ST-elevation myocardial infarction) to speed such patients to definitive care. The American Heart Association (AHA) and its division, the American Stroke Association (ASA), recently issued a joint policy statement, ˙Implementation Strategies for [EMS] Within Stroke Systems of Care.Ó
The paper includes four key recommendations for a stroke system:
> Require appropriate processes for activating and dispatchingEMS response to ensure rapid access for acute stroke patients;
> EnsureEMS responders use protocols, tools and training that meet current AHA/ASA guidelines;
> CreateEMS training, assessment, treatment and transportation protocols for stroke via collaboration between prehospital providers, emergency physicians and stroke experts; and
> Transport stroke patients to the nearest stroke center if such a center is within a ˙reasonable transport distance and transport time.Ó
Each major recommendation includes numerous suggestions for accomplishing them. For example, the fourth recommendation outlines five specific concerns and potential strategies for addressing transport issues.
Many physicians have been slow to adopt the use of thrombolytics (also known as tPA) for stoke patients because of concerns that the clot-buster might mistakenly be used following a hemorrhagic stroke that was misdiagnosed as an ischemic stroke (caused by a blood clot), causing further bleeding.
However, a new study may change that situation: It found that 29 of 33 lawsuits related to the use of tPA for stroke involved cases in which physicians failed to give thrombolytics. ˙It would appear from this study that not giving tPA for eligible patients in the emergency department may be the primary source of litigation associated with this policy,Ó says the study_s lead author Bryan A. Liang, MD, PhD, JD, a faculty member at theUniversity ofCalifornia San Diego and California Western School of Law. (Liang BA, Zivin JA: ˙Empirical characteristics of litigation involving tissue plasminogen activator and ischemic stroke.ÓAnnals of Emergency Medicine. ePub. March 4, 2008.)
Some EMS administrators also have expressed concerns that failure to follow AHA/ASA stroke system guidelines could exposeEMS systems to liability. So don_t be surprised if a stroke network comes to your neighborhood soon. View the AHA paper athttp://stroke.ahajournals.org/cgi/reprint/STROKEAHA.107.186094.; ƒMG
D.C. Re-Tests All Paramedics
TheDistrict of Columbia announced in February that the Maryland Fire and Rescue Institute would test all 250 D.C. Fire andEMS paramedics in March to ensure their competency. ˙I expect there will be people [who] fail this process,Ó DCFEMS Chief Medical Officer Michael D. Williams, MD, told the Washington Post. ˙And I think I will be saying, ÂYou_re really not functioning as a paramedic, so we_re going to pull you out._Ó Paramedics with minor deficiencies will be retrained, he said, and those who don't improve with remedial training will be reassigned as EMTs. The competency testing was recommended by a task force formed to improve DCFEMS to settle a lawsuit filed by the family of New York Times journalist David Rosenbaum, who died after an alleged improper response to a head injury sustained in a mugging.
Last MAST Unit Deploys
For decades, remote areas of several states had air-medical services only because of the Military Assistance to Safety and Traffic (MAST) service. However, since the U.S went to war inAfghanistan andIraq, MAST units increasingly have been deployed overseas instead. In February, the military notified Alaskan officials that the last MAST unit would be deployed July 1, according to the Fairbanks Daily News-Miner.
NAMES IN THE NEWS
Tore Laerdal & Jullette Saussy Receive Top Awards: The U.S. Metropolitan Municipalities EMS Medical Directors Consortium awarded its top honors to Tore Laerdal, chairman of Laerdal Medical AS, of Stavanger, Norway, and Jullette Saussy, MD, medical director and director of New Orleans EMS, at the 2008 EMS State of the Sciences Conference on Feb. 22 in Dallas.
Tore Laerdal received the Paul E. Pepe Excellence in EMS Award for individuals who have provided far-reaching contributions or leadership in prehospital emergency care and whose accomplishments have had significant impact on the performance and conditions ofEMS personnel and 9-1-1 systems.
Jullette Saussy received the Michael Keys Copass Award, presented to anEMS medical director who has demonstrated superior long-standing service, contributions and leadership.
Saussy also recently received the Keith Neely Outstanding Contribution Award from the National Association of EMS Physicians given for outstanding contributions to prehospital emergency care and The Tema Contra Memorial Trust Public Service Award inToronto,Canada.
EMS TODAY AWARDS:
During the closingceremony on March 29 of the EMS Today Conference and Exposition, several distinct honors were awarded. The first was the Nicholas Rosecrans Award presented toFrisco (Texas) Fire Department for their ˙SafetyTown,Ó a simulated town used to educate children on injury prevention. Next was the Prehospital Care Research Forum award for Best Abstract, which went toMyles Jen Kin, MA, MS-I, EMT-B, andBaxter Larmon, PhD, MICP, for ˙Prehospital Glucometry: Capillary vs. Venous Whole-Blood Glucose Measurements.ÓMark Venuti ofFlagstaff,Ariz., received the James O. Page/JEMS Leadership Award. The ceremony ended with theFire Department of New York team receiving first place medals for the JEMS Games. For more on these awards, visitwww.jems.com.
Restrained Patients = Legal Risk
The media recently reported on an incident in which two EMTs used duct tape to restrain a male patient during a transport from a nursing home to a local hospital, although the ambulance carried padded leather restraints. The EMTs claimed the patient, who had a history of psychiatric problems, posed a danger to them and the nursing-home staff. Media coverage of this incident and others involving improperly restrained patients reminds us that it_s vital to have clear restraint policies and to treat patients with dignity and respect in all situations.
A patient who_s violent and aggressiveƒwhether due to drugs, alcohol, or a physical or psychological conditionƒposes a difficult situation forEMS personnel. Aside from personal safety, the main priority must be to ensure the patient receives appropriate and respectful medical care. On rare occasions, this may require restraining the patient for the safety of everyoneƒ including the patient. However, improper restraint and/or using excessive force can have legal consequences.
Although the law is fairly strict on what_s allowed in hospitals or nursing homes, most federal and state laws and regulations don_t address the use of restraints in the prehospital setting. We all have the basic right not to have our ˙liberty of movementÓ restricted by others, except in very unique situations. AlthoughEMS agencies often confront such unique situations, many don_t have well-defined restraint protocols. This leavesEMS personnel at a disadvantage when defending a lawsuit for improper restraint. Lawsuits againstEMS personnel are founded in several theories, including false imprisonment, assault, battery and wrongful death.
Violent patients do have a right to refuse treatmentƒif they_re competent. But violent patients often are incompetent and unable to refuse treatment because they_re physically or mentally ill or are under the influence of mind-altering substances.
Unfortunately,EMS personnel are burdened with the difficult task of determining whether or not a patient is capable of making an informed decision. The patient must have the mental capacity to make decisions in order to refuse treatmentƒthe patient must be alert and oriented to time, place, person and situation and not under the influence of drugs or alcohol. If the patient then refuses treatment,EMS personnel run the risk of being sued for false imprisonment if they subject that patient to physical or chemical restraints. If a patient without decision-making capacity is subjected to improper restraint,EMS personnel could be sued for using excessive force or for wrongful death if the patient dies.
Having a well-defined restraint policy (consistent with state and federal laws) is crucial forEMS systems and personnel, and adherence to proper restraint procedures can be critical in defending a lawsuit. But manyEMS personnel are inadequately trained on restraining violent patients, and patient-refusal policies often fail to address situations involving violent patients.
Most important: Always treat the patient with respect and dignity whenever restraints must be used. Restraints are a blow to one_s dignity and are very humiliating. They should be used only when all other methods of patient control have failed.
For a good example of a restraint policy, download theRiversideCounty (Calif.)EMS protocol atwww.rivcoems.org/downloads/downloads_documents/Protocol102904/5000.pdf. You can also read ˙Exercise RestraintÓ in March 2002JEMS. JEMS
This update is provided bySteve Wirth, Doug Wolfberg&Ryan Stark of Page,Wolfberg& Wirth LLC (www.pwwemslaw. com), a nationalEMS, ambulance and medical transportation industry law firm.