The Unified Power of Thousands, Part 2: The Promise (and Problem) of Convergence in Mobile Medicine

Jonathon Feit

Editor’s note: Read Part 1 here.

The Lifesavers Conference on Roadway Safety is one of two national conferences that I kept hearing are the place to be when it comes to post-crash care. The other is the Governors Highway Safety Association conference.

For those who are unfamiliar with the term, “post-crash care” refers to the portion of the National Roadway Safety Strategy (NRSS) that—not to put too fine a point on it—features an ambulance on the logo. Which is not to say that everyone involved in the NRSS knows how ambulances work, but we’ll get them there in time.

As is typical of a federal initiative, “post-crash care” is broad. Recently at Lifesavers, Gregory Colton, Community Outreach Captain at the UC Health EMS and the Hudson Center for Prenatal Vehicle Safety (divisions of the University of Colorado Health System) noted that it should include everything from first response—which may not be provided by a medic or firefighter, but indeed, even includes bystanders—to the receiving facility, even to post-discharge follow-up depending on the nature of the patient’s needs.

Post-crash care is all of it. It incorporates whole blood delivery. Could it also include law enforcement phlebotomy, a fascinating and complex topic of conversation at this event?

Post-crash care is kind of a lot…but focus on it is essential and overdue. According to the U.S. Department of Transportation, roadways deaths are a “crisis that is killing more than 40,000 people on American roads each year…the dramatic increase in roadway fatalities seen during the pandemic has begun to level out but remains far too high with an estimated 42,795 people dying in motor vehicle traffic crashes in 2022. This represents a small decrease of about 0.3% as compared to the 42,939 fatalities reported for 2021.”  This figure only pertains to deaths. It does not include debilitating, costly, and often lifelong injuries.

Yet, post-crash care’s breadth also makes it thorny—lots of lines get crossed. My eyebrows rose at the notion of public safety officers drawing blood following a DUI on the side of the road. They rose a bit higher at the pervasiveness of this discussion without (to my ears, anyway) hesitation: it came up several times in settings from panel presentations to lunchtime chats about prosecuting impaired driving.

It was a key focus of a working group about data interoperability to get a nationwide handle on who and where impaired driving is happening so that state traffic safety offices can staunch the disaster of a person driving a weapon of mass destruction-on-wheels into someone whose life will be forever altered, or ended.

Post-crash care is therefore also pointedly emotional. With the exception of an amazing concept car that I saw at the 2024 CES conference in Las Vegas (it moves laterally…and it was bona fide amazing), cars and trucks still cannot move out of the way of drunk drivers.

BUT…

Lots of lines are getting crossed. Convergence happens when lines combine, and as all who know me (or read this column regularly) can attest, I am passionate about converging our profession’s many patch colors. I don’t discriminate among those whose mission is to care for their communities; to the contrary, I believe tribalism is a parasite sucking out our political power.

Especially at a moment when the fire, ambulance, police, nursing, and medical service lines are all struggling to hire and retain talent, we need everyone working together.

As such, I am inspired by medical leaders within the Texas Department of Public Safety and the California Highway Patrol.  It is insightful for law enforcement agencies to have a medical command in light of the number of motor vehicle crashes happening rural roads, far from a fire or ambulance station. So often, the first on-scene is a patrolman or deputy sheriff.

Converge is a very good thing, and as Capt. Colton noted, it is natural to our work: during major disasters, everyone shows up. Politics wait.

But convergence—the center of a Venn diagram—means alignment. It does not mean ambulance, fire and public safety services are the same. Everyone goes in; none gets to say “this is just too hard.” But each service carries its own tools, follows distinct protocols and is bound by its idiosyncratic rules.

Law enforcement phlebotomy is an interesting one: it calls into question some relevant boundaries while at the same time offering a powerful opportunity for interoperability (and Rob Duckworth, the former director of Indiana’s Office of Traffic Safety, noted that it even has implications for community paramedicine, a part of our world that simply thrives on interoperability).

According to the U.S. Department of Justice, law enforcement phlebotomy engages public safety officers within a specific unit (in the DOJ’s cited example, Arizona calls them a “DUI Squad”) are “all certified phlebotomists, so they can quickly obtain search warrants from the arrest scene and ensure a proper chain of custody for the blood drawn…Prior to developing an in-house operation, the DPS relied on hospital phlebotomists to draw blood if consent was given and a breath screening device was not immediately available; however, some civilian phlebotomists were hesitant about drawing blood from uncooperative DUI suspects due to unfounded legal concerns.”

In 2019, NHTSA published the Law Enforcement Phlebotomy Toolkit: A Guide to Assist Law Enforcement Agencies With Planning and Implementing a Phlebotomy Program. At Lifesavers, I attended a reception at which the same company that makes a tool for blood gas analysis in a medical context explained its technologies for “forensic analysis,” that is, at-the-vehicle measurement of blood chemistry by public safety professionals.

I raised a concern: Some substances should never be in a driver’s blood. We can agree that driving drunk is heinous and should be punished harshly. But in many states, driving while impaired is not limited to alcohol or illicit drugs.

It can also result from medicines taken (or not taken), or interactions between medicines. In 2009—fifteen years ago, NHTSA published a largely ignored paper that I am committed to injecting into our professional consciousness: Bluntly titled “The Contribution of  Medical Conditions to Passenger Vehicle Crashes,” it highlights the prevalence of clinical factors as the proximate cause of MVAs.

If the car was swerving or if the driver crashed, but if he or she was suddenly hypoglycemic, experiencing an acute MI, or syncopal due to an accidentally overdose of blood pressure medication (a case described in 2021 by former Harris County ESD 48 Community Paramedicine Joseph Casciotti at a National Association of Mobile Integrated Health Providers conference)…the person being pulled over is not an “offender.” He or she is a patient.

Can public safety officers using roadside chemistry tools contextualize test results by pinging the health information exchange or prescription drug monitoring program to understand what medications the patient has been lawfully prescribed? In most jurisdictions, the answer is simple: No.

Duckworth looked to community paramedicine: Companies have begun exhibiting at CP/MIH conferences about point-of-care lab testing to be used in the home. But many CP/MIH patients are polychronic, and powerful medications for their several conditions can interact in unanticipated ways.

In diabetics like my father, blood sugar can rise or fall precipitously—due to a lack of food, too much insulin, or even the start of a common cold. Some patients with epilepsy can tell that a seizure is about to happen, but so-called “auras” may occur seconds before a broader loss of control. If the person is driving, he or she may not have a chance to pull over. This scenario is not theoretical: patients with epilepsy cannot drive in just sixteen countries

With an increasing number of cases questioning medics’ decision to administer this medication or perform that procedure without full knowledge of a patient’s underlying health (especially where Mobile Medical services could use the regional health information exchange, but do not do so for a variety of reasons, from technology limitations to workflows), do law enforcement phlebotomists have sufficient context?

So many lawyers’ websites reference medical conditions as grounds for DUI dismissal but consider the stress to patients who have to go through the legal process when they may not have even known they were impaired at the time of the crash (hence, the 2009 NHTSA statistics citing medical causes).

In Mobile Medicine, we speak often about the cognitive dissonance of billing patients for care they needed at the time but that they later cannot afford. Should law enforcement professionals ask whether they are being given enough data to determine whether or not a substance in the patient’s blood is supposed to be there?

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