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Reader Mail: The Continuing Saga

Lt. John Kaltenbach of Gahanna, Ohio, objects to my characterization of the organizational culture of EMS agencies (Why We Can't All Just Get Along, Part I and Why We Can't All Just Get Along, Part II). He observes that although I focus on field staff, I don't give any background about how ED staff would handle the same scenario. He also feels that I inappropriately characterize the fire service personnel he knows as more interested in fighting fires than saving lives.

To an extent, the lieutenant is correct. This wasn't a "compare and contrast" type of article. There are clearly the seeds of another work there, to evaluate the organizational cultures of a fire or EMS agency against that of a hospital ED (offhand, I suspect we would find some clear differences in hierarchical structures and "masculine" vs. "feminine" approaches to tasking, supervision and the desirable qualities of supervisors and employees). But my goal in these pieces was not to identify differences or establish who was "better" or "worse," but simply to point out the idea of organizational culture as a driving force behind why, when and what we do.

I truly don't believe that all individual fire personnel are more concerned with firefighting than with EMS. I think attitude varies from one individual to the next, as attitudes tend to do; we all have tasks in our jobs that we like better than others. I do think, however, that when you look at the organizational culture of most fire services, it's still very much based on firefighting. To me, this is really a generational effect: Many of the current leaders in the fire service "grew up" professionally in a different era, when EMS was not the primary function of many fire services and where ALS was a mystery seen only on TV. Early experience shapes views forever. I think we can all identify departments where the fire chief never moved beyond an initial certification, leaving EMS matters in the hands of a deputy; and I think we all know departments where promotion is based on seniority and progression up the fire ladder, rather than on quality of patient care and advanced EMS knowledge.

I do think this mindset is changing. The next generation of fire service leaders has matured in an era where the majority of calls for help require EMS. This fact alone will reshape the organizational cultures of fire departments as these younger individuals assume leadership positions. I hope that Lt. Kaltenbach's feelings toward my work are a function of the fact that in his area, fire services have already made this transition. Unfortunately, change is slower elsewhere. Looking at the organizational culture of a fire or EMS service helps to identify both organizational assets and obstacles to progress.

Legal Liability & Documentation Terminology

From somewhere in Indiana, Aaron Kreag writes to ask if there is any legal liability in the shift from using the term "non-compliance" to the phrase "non-adherence." You may recall that the shift was initiated by politically correct medical linguists to suggest that the provider bears some responsibility for the patient's inability to comply fully with clinical advice. (In my opinion, that's probably true in some cases. However, it's not so rampant that it mandates a new word.) I don't think that this change in terminology makes much of a difference in the degree of liability. Since we've entered the era of legal medicine, the content and manner of providing medical information have already been subject to extensive litigation. Many cases already revolve around what the patient was told, or not told, to do. So take the story for what it's worth, and recall that honest advice based on your education and training, topped off with a dollop of human kindness, is probably the best, and safest, advice of all.

Dear Sucker

Something I mistook for reader mail that you might be interested in: One Phillip Weah, Personal Assistant to Charles Taylor, the past president of Liberia, is searching for a "foreigner" to take possession of a large portion of Mr. Taylor's personal fortune before the government of the United States freezes his assets. "Adequate renumeration" [sic] will be provided for these services. Just thought I'd let you know.

The Malpractice Morass

After two failed special sessions, the Florida legislature finally agreed on a malpractice bill that makes nobody happy. In brief, it says that non-economic damages (pain, suffering, etc.) are limited to $500,000 per claimant (the person suing) and the total damages recovered by all claimants is limited to $1 million. No individual practitioner is liable for more than $500,000. However, this cap may be "pierced" to make each individual liable for up to a cool million for each claimant in cases where death, chronic vegetative states or "catastrophic injuries" are the alleged result of the negligent care. Needless to say, this is a far cry from the "hard cap" of $250,000 initially advocated by the governor, the State House of Representatives and the medical community.

The only people who made out well (sort of) were practitioners providing emergency care, where non-economic damages are capped at $150,000 per claimant to a total of $300,000. This is a true "hard cap" and cannot be pierced. Insurance companies get a break as well. They have to freeze their malpractice premiums until January 2004, at which time they may file and be approved for reduced rates. However, there is no prohibition against raising malpractice premiums after the turn of the year.

Nobody likes this agreement. Doctors aren't happy and are pushing for a constitutional amendment to limit the amount an attorney can take from the proceeds of a suit. Attorneys aren't happy with the damage limits. The insurance companies can still raise rates if they can justify it (and who can't?), which simply compounds the damage. The people who need care are still, as always, caught in the middle.

Remember the Trauma Center issue? It hasn't gone away. While our trauma surgeons are still on the job in Daytona, the Level I Center in Orlando is on the ropes again. They had developed a funding plan by which all the surrounding counties would contribute to the upkeep. However, the richest of these counties (and the one asked to take the largest burden) decided not to fund its portion of the cost. In an interview, the chair of this county (located between Daytona and Orlando) smugly implied that this was not a problem. The Level I Center in Orlando will not shut down; and even if it does, there's always Daytona to pick up the slack. He's right, of course. Ethically, we can't and won't refuse any critical patient the care they deserve. But the cynicism of his view is distasteful at best, and it can be galling to accept patients from places that cannot see the value in what you do.

And one other small, but significant way the malpractice mess has affected patient care: Last Sunday night in the ED, I saw a 23-year-old woman who presented with vaginal bleeding and was concerned that she might have had a miscarriage. She had an ultrasound done in a clinic three days before that showed a viable 12-week pregnancy. However, I was unable to hear fetal heart tones with an amplifier (Doppler) device, and a brief review of her old records indicated that she had never had a blood pregnancy test performed (such tests measure beta-HCG, a hormone released during pregnancy. The level of b-HCG in early pregnancy rises and falls at relatively predictable rates, so it is a useful tool to track the status of a pregnancy). The only way I could tell her whether she had suffered a miscarriage or not was to get another ultrasound to check for a fetal heartbeat. This is a procedure I'm not trained to do, so I referred her for an emergent ultrasound study of the pelvis simply to see if there was still a fetal heartbeat. The patient went to ultrasound and was immediately sent back. Radiology refused to do the study because the first glance demonstrated that the fetus was more than twelve weeks old. Thinking that if they did enough of an ultrasound to tell the dates, I figured they would have been able to see a heartbeat or not. However, the radiologist told me he couldn't give me any information, as he wasn't covered by his insurance carrier to perform and interpret that procedure once it was determined that the fetus was more than 12 weeks old.

I know the radiologist personally, and he's not a bad guy. I have no doubt that in other circumstances, he'd give me the data I wanted and more. And although I don't like it, I understand his conflict. Why should he do a procedure or provide me with information if he's not covered by his insurance to do so? What if he's human and gets it wrong as humans occasionally do?

So I had to tell this lady that I had no way to tell her what's going on, give her a handout on miscarriage precautions and have her walk around for the next three days waiting for the clinic to tell her if the fetus is dead. And I can guarantee you that the wives and daughters of our legislators, attorneys, corporate executives and physicians, those with ready access to care who can call their private physicians in the middle of the night, will never see this problem. And that's the real malpractice crisis.

As always, thanks for your notes of criticism, support and comment. I look forward to hearing from you.


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