A new case from the Ohio Court of Appeals illustrates what an appellate court may consider in order to affirm the termination of a paramedic on grounds of incompetence. Melanie Snyder was a paramedic with the Township of Beavercreek (Ohio) Fire Department. She was terminated after an incident in which she administered D50 via an endotracheal (ET) tube during a cardiac arrest. The case also shows that a failure to admit and deal with medical errors will be considered a reason for severe discipline.
Snyder responded to a cardiac arrest along with her partner, firefighter/paramedic Ryan Williams, who was the senior paramedic on scene and acting as the Officer in Charge. Other crew members attempted to initiate an IV, began CPR and attempted to accomplish ET intubation. Learning that the patient was an insulin-dependent diabetic, Snyder asked for the patient's blood sugar to be checked. The level was 41. Snyder indicated that they needed to "look at" the blood sugar level as a possible cause of the arrest. Williams told her that they needed to get an IV and administer cardiac resuscitation medications prior to dealing with the blood sugar.
Snyder assisted with insertion of the ET tube. Once intubation had been accomplished, she administered the first dose of epinephrine via the endotracheal route. She then retrieved an ampule of D50 as well as another of epinephrine from the drug bag. Although she heard someone say that an IV had been established, she proceeded to administer the D50 down the ET tube. She then performed a second glucometry check and found the patient's blood sugar to be 79. The patient was transported to the hospital, but was pronounced dead.
Shortly thereafter, another paramedic who had responded to the cardiac arrest telephoned Snyder to tell her he had to document the fact that she had put D50 down the ET tube. She exclaimed, "Oh, my God. I must have done that. I did that, didn't I?" Snyder was later notified in writing that she was being charged with "misfeasance and gross neglect of duty" based on the failure to follow a supervisor's order and failure to maintain proficiency and knowledge of protocols.
Snyder fought her termination, citing a lack of previous disciplinary problems or medical errors. During the administrative hearings before the Beavercreek Township Board of Trustees that followed her termination, Snyder testified that she thought she had handed the D50 to the person who said they had started an IV, and thought she grabbed the epinephrine, and that is what she had believed she was pushing down the ET tube. She admitted that she had no specific memory of administering either drug, despite the difference in viscosity and the time it would take to push the two drugs.
The Board found that Snyder's testimony was not credible, finding that her recall of the details of this incident were excellent, with the exception of her memory of her error. They noted that she accurately recalled the names of each responding EMT, what she did when she first arrived and the patient's precise glucometry readings. The Board found that Snyder knew she was pushing D50 at the time she was doing it and that she failed to follow the orders of her supervisor, who said that they should address the cardiac arrest first.
The Board also found that she unequivocally knew, immediately after administering the D50, that she had made a mistake. She testified that during the incident, she found herself holding an empty ampule of D50. The Board found that at that point, she knew that the D50 had gone somewhere but failed to disclose the error. It also found that she knowingly failed to inform the transport crew or the hospital of this error, saying "Ms. Snyder was dishonest when she told Tom Grisner and her supervisor that she did not realize she had made the mistake until she was confronted with it several hours later." Although it was clear that the patient had died of a heart attack, and that Snyder's error had not contributed to his death, her employment was terminated.
Snyder appealed her termination to the district court, which affirmed the Board. Snyder then took her case to the appeals court. During the appeal, Snyder pointed out that the documentation of the event did not support a finding that she had administered the drug. However, the appellate court noted that her case before the Board stated that although she made an error, she did not intentionally fail to obey the senior medic's orders and that the evidence showed she had told the patient's widow that she had administered the D50. The fact that she changed her story on appeal greatly helped convince the court that she should be terminated.
There are some lessons to be learned from this unfortunate case. It's unclear how none of the other EMTs at this cardiac arrest scene noticed that Snyder was administering D50 down the ET tube, and if they did, why they failed to stop her. It takes some time to push an entire ampule of D50, and with CPR ongoing, it seems that someone should have taken note of this error as it was being made.
Further, the case does not discuss any interaction with the service medical director, who Snyder should have contacted immediately about this serious drug error. The fact that there was no documentation of the mistake, and Snyder's attempt to use that fact in her defense, is further evidence of her dishonesty.
Errors happen. But when they do, the proper and in fact, the only course of action is to promptly report them through the chain of command and to the medical director, always keeping the patient's interests first.