Case 1: Jim and his partner are dispatched to a medical aid ˙unknown problemÓ at1057 Willow St. When they arrive at the upscale residence, they find a 40-year-old female sitting on the porch, who says she hasn't been feeling well all morning and her husband is out of town on business, thus the 9-1-1 call.
Jim's assessment doesn't reveal anything unusual. Her radial pulse is a little fast at 96 but is strong and regular. Respirations and blood pressure are within normal limits. Skin appears to be normal in color, moisture level and temperature. Lung sounds are clear in all fields. Her level of consciousness (LOC) is normal with the exception of being anxious, and her pupils are reactive at 4 mm. A quick check of the monitor shows a normal sinus rhythm and 98% PO. The secondary exam also appears normal, and her medical history is clean except for a recent diagnosis of bipolar disorder.
After hearing the crew's findings and being encouraged to go to the hospital, the patient agrees to the transport as long as she'll be taken to her hospital of choice. Her vital signs remain stable for the first 15 minutes of the transport. At this point, she begins to complain of shortness of breath and chest pain, quickly followed by a decreasing LOC. Jim lowers the head of the gurney and places a non-rebreather oxygen mask on her face.
The monitor shows ventricular tachycardia (VT). He opens the patient's blouse to facilitate the placement of defib pads, and as quickly as the VT appeared, it changes back to a sinus tachycardia with premature ventricular contractions (PVCs).
Little does Jim know, his lifesaving actions are perceived by the patient as anything but lifesaving. She recounts the episode to her husband at the hospital, telling him the male paramedic opened her blouse and touched her inappropriately.
Case 2: Ryan and the rest of his ALS crew are transporting a patient with severe depression and a history of mental illness. En route to the emergency department (ED), Ryan conducts routine monitoring of vital signs and notes no change in her status. The crew transfers the patient to the custody of ED staff, and once the paperwork is completed, leaves the hospital, never expecting any further contact with the patient.
However, the patient goes on to tell her physician that the male paramedic fondled her breast during transport. Ryan's supervisor and a police officer confront his crew before the end of their shift. He's accused of ˙inappropriate touching and fondling of a female patient,Ó and although he's not taken into custody, he's immediately removed from the field and placed on administrative duty.
In both cases, the crews were required to submit a written report documenting their actions. The EMS personnel had managed their patients in the same manner and scope as on previous calls, but these two patients suddenly, and without warning, presented them with potentially career-ending allegations, or worse. Despite the impeccable records of the experienced paramedics involved, the patient accusations deeply affected them and led to one criminal investigation. Sadly, the word of a paramedic wasn't enough to resolve the allegations.
None of us can prevent these kinds of personal attacks, even when using textbook assessment techniques and providing outstanding patient care and compassion. But what we can do is insulate our patient encounters with appropriate technology. This is why the first case was quickly vindicated and the second case dragged on for more than six months.
A New Kind of Documentation
The San Diego Fire-Rescue Department (SDFD) and Rural/ Metro Corp. operate the city's EMS system via a partnership, the San Diego Medical Services Enterprise (SDMSE), and work as a seamless team on more than 100,000 calls annually. Protocols and equipment are unified under one medical director, which minimizes patient-care issues.
The 350 square miles ofSan Diego city are covered by 58 ALS first responders and an average of 27 ALS ambulances, all utilizing the same equipment and documentation protocols. One of the key pieces of equipment deployed is the ZOLL M Series monitor, which includes several key components: 12-lead ECG, capnography, oxygen saturation, digital data recordingand digital voice recording.
All patient contacts and transports have data captured by the digital card in the monitor. SDMSE policies require that for critical patients providers must upload digital data from the monitor to the station computer, which then transmits that data to a central department server. For routine calls and stable patients, the data is routinely erased at the end of the call. Uploaded data is reviewed for quality assurance (QA)/quality improvement (QI) processes and permanently stored for future reference. This data provides objective information -- a voice recording of any conversation in the room or ambulance where the patient is being monitored. This data can become evidence.
A Quick Resolution
In Case 1, the patient and her husband were provided with a full explanation of the sequence of events that led to the male paramedic opening her blouse. For most reasonable patients, this explanation would have sufficed. But everyEMS system has likely encountered a stubborn patient and/or family member who refused to believe anything but what they were initially told. In this case, the family wouldn't accept the explanations of the ED or SDMSE staff. Not only was the call destined for the legal arena, but the mental anguish it caused for the patient and the accused crew was substantial.
The QA staff of SDMSE had the patient and her husband listen to the entire digital voice recording of the call from initial contact to transfer at the ED. It only took a few minutes for the family to acclimate to the voice subtleties and distinguish between the crew member driving the ambulance and the voice of the paramedic caring for the patient.
They were then able to hear the paramedic telling his partner she had gone into VT. The sound of the defibrillator pad packet being opened soon followed. This indicated that the opening of the blouse was required. This series of events confirmed that only appropriate patient-care activities took place during transport. The allegations were withdrawn -- case closed, lessons learned.
An Unnecessarily Slow Resolution
Case 2 wasn't resolved with voice-recording technology due to the patient's condition. When a patient is stable, there's no need to monitor their ECG. Thus, voice-recording capabilities are turned off. Additionally, data captured by the cardiac monitor is uploaded only after critical calls.
This routine transport became a time bomb ready to explode and ruin the life of an excellent paramedic. Fortunately for the paramedic, the truth finally came out, but not until after a six-month investigation. During the investigation, another piece of the patient's history was uncovered; she had made false accusations against other medical staff on two prior occasions.
However, until the case was finally resolved, the paramedic involved was subjected to several interviews by the police department's sex-crimes unit and months of questions and rumors. Despite efforts by all involved agencies and parties to keep this investigation confidential, rumors got out, and the reputation of an outstanding paramedic was tarnished. This caused members of the department to ask, ˙Why is he on administrative duty?Ó
Proven Results & Benefits
SDFD began using voice recordings as part of its initial AED program more than 10 years before purchasing ZOLL monitors for the first-responder units. In 1997, voice recordings became the standard for all ALS vehicles via the cardiac monitor. For two decades, these voice recordings have served to provide objective information about thousands of critical calls. Per an agreement between SDMSE and Local 145 (the union for our firefighters, paramedics and EMTs), the information derived during QA review of voice recordings is used for QA/QI purposes and not department discipline.
As a best practice, every EMS system should want the truth, good or bad. We should ensure that we're on the front end of an incident, equipped with all the facts, not just recollections of the facts. If we make a mistake, we must own it; and if we're being falsely accused, we should want that to come out also. Voice recordings have served to clarify hundreds of questions on calls in our department and have vindicated dozens of crews that have been falsely accused. Not once has a voice recording been used to discipline an employee.
Crews have also found ways to use the voice capture beyond ourEMS system policies. Here are some examples of ways in which the use of on-scene voice recording has been beneficial:
If voice capture is new to your system, taking the concept to the employees or their representatives before implementing it will go a long way toward its acceptance by your department members. You want to gain their support rather than making them feel they're being spied on.
Without voice capture, your agency leaves itself exposed and limits its ability to factually defend the actions of crews. This is the reason dash-mounted cameras have become standard in law-enforcement vehicles. Objective data collection of the actual events of an incident as they occur makes answering questions about that call much easier and more acceptable for our patients.
If you're ever accused of wrongdoing, you need to know the truth before the plaintiff's attorney educates you on the facts. Take the next step by contacting a major manufacturer of monitors with voice capture: ZOLL, Philips or Physio-Control.
How do you address your staff's "Big Brother" fear? It can be as simple as pointing out that if they don't want something recorded, they shouldn't say it. And remember, even if you choose not to upgrade your monitor to include voice capture, it doesn't mean your calls won't be recorded. Every EMT and paramedic should assume all calls are being recorded by a bystander with a video camera or cell phone -- if you don't believe it, check out YouTube. So rather than ending up as an accidental celebrity, I recommend that you be proactive in monitoring the care you render -- in order to protect your patients and yourself.
This article originally appeared in January 2008 JEMS as "Nothing But The Truth: How voice-recording technology can save your career."