It is the first of its kind to reverse the decision of an EMS medical director with respect to a medical control decision. In most states, EMS medical directors generally have significant latitude in requiring remediation as well as in withdrawing or limiting medical control supervision of an individual EMS provider. The complex bureaucratic process involved in this case appears to undermine the authority of the medical director, and potentially leaves the medical director without sufficient recourse to enforce his supervisory authority over patient care.
Background
Pennsylvania law requires a person to obtain MCA in order to be a paramedic. MCA is defined as “permission given by the service’s ALS medical director to perform, on behalf of an ALS ambulance service, ALS services under medical command or in accordance with department-approved regional EMS medical treatment protocols.”
The regulations further state that the medical director determines whether “to grant, deny or restrict MCA to a paramedic who seeks to provide EMS on behalf of an ALS ambulance service.” The medical director is required to document how the decision is made. If she or he denies or restricts an individual’s MCA, it must be done “in a written document provided to the individual.” After initially granting MCA, the medical director is required to review each paramedic’s MCA annually to insure that the paramedic “has demonstrated competence “¦ in performing each of the services that fall within the scope of the individual’s MCA.” Pursuant to the annual review, the medical director may renew MCA, renew with a requirement of continccuing education in any field deemed appropriate, restrict MCA or withdraw it entirely.
If the medical director determines that MCA should be restricted, the restriction “must not preclude the individual from performing the services specified within the scope of the individual’s certification or recognition as permitted by the medical treatment protocols for the region.” Thus, acceptable restrictions include a requirement for on-scene supervision, or permitting certain skills to be performed only with on-line medical control.
A paramedic can appeal denial of MCA to the regional EMS medical director and request a hearing, after which the regional EMS medical director will render a written decision. If the paramedic then disagrees with the regional EMS medical director’s decision, they may appeal to the Department of Health, which will review the record and may hear additional argument and evidence. It will then issue a final decision.
The Cheltenham Township case
Fox was hired in January 2009 and Rubin granted restricted MCA for initial service precepting. Fox obtained full MCA within a few months but then went on six months leave for a non work-related injury.
Fox returned to work under a rotating preceptor arrangement and, a few days later, responded to a motor vehicle crash along with two other paramedics, Mike Riley and Michael Smaltini. Riley was precepting Fox during this incident. Fox administered two doses of Versed to the patient to facilitate intubation, in violation of statewide protocol. He administered the first dose without obtaining on-line medical control; the second dose was authorized.
The record indicates that Riley witnessed Fox administer the first dose but didn’t attempt to prohibit him. Fox prepared a patient care report after the call, and Riley edited it. All three paramedics submitted an incident report. Rubin interviewed Riley and Smaltini but didn’t interview Fox. He commented that the overall care appeared to be good, and that the authorization for the second dose of Versed was tacit approval of the first dose, which had been given in violation of protocol.
Although Rubin required Fox to take an airway course, he didn’t restrict his MCA due to his years of service. Two weeks later, Rubin withdrew Fox’s medical control, but didn’t provide the form or any formal paperwork to Fox indicating that his MCA was withdrawn, instead presuming that the service would do so. Fox was notified of the withdrawal verbally by Smaltini and the EMS service director at a meeting during which he was also terminated.
Fox appealed to Benjamin R. Usatch, MD, the Montgomery County regional EMS medical director. Subsequently, Rubin changed the withdrawal to a restriction, requiring 100 hours of continuing education before the restriction would be lifted. Rubin intended to restrict Fox from working until he completed the continuing education. Fox appealed the restriction. It was dismissed and Fox appealed to the Department of Health.
The department heard the issue of whether Rubin’s withdrawal and subsequent restriction of Fox’s MCA comported with its regulations. The hearing officer determined that Rubin had never directly spoken with Fox and never offered Fox the opportunity to rebut the allegations. He further found that Rubin failed to document the reasons for the withdrawal of MCA, and that further investigation should have been done after the incident.
The hearing officer also determined that Riley was supposed to be precepting Fox but that there was clearly a lack of supervision when Fox administered the first dose of Versed. Ultimately, the hearing officer found that Rubin failed to meet his burden, and that there was insufficient evidence showing that Fox was incompetent enough to warrant withdrawal of MCA.
Rubin appealed to the court on the grounds that a protocol violation is sufficient, in and of itself, to warrant withdrawal of MCA. The court found that Rubin had performed an inadequate investigation by failing to interview Fox, and that he had failed to justify the disparity in discipline of Fox and Riley, and agreed with the Department to overturn Rubin’s decision.
This case provides a look into the very detailed procedural requirements for restriction or withdrawal of EMS medical control in Pennsylvania. Many states do not afford EMS this level of due process under similar circumstances. The presence of this detailed process appears to undermine the authority of the EMS medical director while providing EMS personnel with significant rights to have a decision reviewed. Whether this ultimately helps or hurts the quality of EMS care is an issue to consider.
Reference:
Dr. Leonard Rubin, Cheltenham Township Emergency Medical Services Medical Director, and Cheltenham County Emergency Medical Service v. Jeremy Fox, 60 A.3d 179 (Commonwealth Court of Pennsylvania).
