Medical-legal communications scenario

March 12, 2008

It's been a while since we've had a good legal scenario on here, so here's

one for y'all to discuss amongst yourselves.

You are a certified (or licensed) EMS provider (ECA, EMT, EMT-I, EMT-P, it

doesn't matter) who is fully credentialed as a 911 provider for your local EMS

agency. You've recently been injured and have been assigned to light duty

at your dispatch center. You receive a call and begin applying your EMD

protocols. During the course of reading/applying the EMD protocols, you find

that

the pre-arrival instructions are contraindicated for your patient's actual

condition. (For example, the cards instruct your patient to lay down for a

respiratory condition when your patient actually has CHF.)

Since you're licensed/certified to practice to your level of EMS

certification, how do you reconcile your standard of care as an EMS provider

with your

obligation to follow the EMD instructions?

Would your answer differ if you were not EMS certified and were instead

working just as the countywide dispatcher for the sheriff, EMS service, and fire

department?

-Wes Ogilvie, MPA, JD, LP

-Attorney/Licensed Paramedic

-Austin, Texas

**************It's Tax Time! Get tips, forms, and advice on AOL Money &

Finance. (http://money.aol.com/tax?NCID=aolprf00030000000001)

March 12, 2008

Ben --

Good point. Let's discuss it either way. Or you could even take it from a

situation where the dispatch center doesn't know it needs a medical director

for its EMD program.

-Wes

In a message dated 3/12/2008 10:46:54 P.M. Central Daylight Time,

ben6308@... writes:

Wes,

Does the same medical director of the EMS Agency (which this medic

is credentialed under) oversee the Dispatch center's EMD Program?

Ben

_ExLngHrn@..._ (mailto:ExLngHrn@...) wrote:

>

> It's been a while since we've had a good legal scenario on here, so

> here's

> one for y'all to discuss amongst yourselves.

>

> You are a certified (or licensed) EMS provider (ECA, EMT, EMT-I,

> EMT-P, it

> doesn't matter) who is fully credentialed as a 911 provider for your

> local EMS

> agency. You've recently been injured and have been assigned to light duty

> at your dispatch center. You receive a call and begin applying your EMD

> protocols. During the course of reading/applying the EMD protocols,

> you find that

> the pre-arrival instructions are contraindicated for your patient's

> actual

> condition. (For example, the cards instruct your patient to lay down

> for a

> respiratory condition when your patient actually has CHF.)

>

> Since you're licensed/certified to practice to your level of EMS

> certification, how do you reconcile your standard of care as an EMS

> provider with your

> obligation to follow the EMD instructions?

>

> Would your answer differ if you were not EMS certified and were instead

> working just as the countywide dispatcher for the sheriff, EMS

> service, and fire

> department?

>

> -Wes Ogilvie, MPA, JD, LP

> -Attorney/Licensed Paramedic

> -Austin, Texas

>

> ************ **************It's Tax Time! Get tips, forms, and ad &

> Finance. (_http://money.http://moneyhttp://money.<WBhttp://mo_

(http://money.aol.com/tax?NCID=aolprf00030000000001)

> <_http://money.http://moneyhttp://money.<WBhttp://mo_

(http://money.aol.com/tax?NCID=aolprf00030000000001) >)

>

March 12, 2008

Wes,

Does the same medical director of the EMS Agency (which this medic

is credentialed under) oversee the Dispatch center's EMD Program?

Ben

ExLngHrn@... wrote:

>

> It's been a while since we've had a good legal scenario on here, so

> here's

> one for y'all to discuss amongst yourselves.

>

> You are a certified (or licensed) EMS provider (ECA, EMT, EMT-I,

> EMT-P, it

> doesn't matter) who is fully credentialed as a 911 provider for your

> local EMS

> agency. You've recently been injured and have been assigned to light duty

> at your dispatch center. You receive a call and begin applying your EMD

> protocols. During the course of reading/applying the EMD protocols,

> you find that

> the pre-arrival instructions are contraindicated for your patient's

> actual

> condition. (For example, the cards instruct your patient to lay down

> for a

> respiratory condition when your patient actually has CHF.)

>

> Since you're licensed/certified to practice to your level of EMS

> certification, how do you reconcile your standard of care as an EMS

> provider with your

> obligation to follow the EMD instructions?

>

> Would your answer differ if you were not EMS certified and were instead

> working just as the countywide dispatcher for the sheriff, EMS

> service, and fire

> department?

>

> -Wes Ogilvie, MPA, JD, LP

> -Attorney/Licensed Paramedic

> -Austin, Texas

>

> **************It's Tax Time! Get tips, forms, and advice on AOL Money &

> Finance. (http://money.aol.com/tax?NCID=aolprf00030000000001

> <http://money.aol.com/tax?NCID=aolprf00030000000001>)

>

March 13, 2008

Wes,

Here is my take on this scenario.

Since I am in the dispatch because of an injury, I am assuming that I am not

EMD certified. Thus I am not going to be covered even if I use the " EMD

protocols " . If I know that what the EMD card is recommending is wrong, I am

responsible to practice at my level of training, the old what would a person

of equal or like training do in the situation. Therefore I would NOT follow

the EMD instructions in this case if I am sure that the patient is in CHF.

Having a patient lie down that has CHF will only cause the patient, if you

can get them to lie down, to become much worse.

As far as non-medical following the EMD cards, they are left with little

choice. If your agency uses the EMD cards, you have to follow the EMD

protocols or your open yourself up to legal and possible disciplinary action

for not following the EMD cards.

I would like to see some independent research done on the EMD system and

either validate the system or prove that the system does not work. Right now

I don't know of any independent studies that have been done on the EMD

system.

Bernie Stafford EMTP

_____

From: texasems-l [mailto:texasems-l ] On

Behalf Of ExLngHrn@...

Sent: Wednesday, March 12, 2008 8:27 PM

To: texasems-l

Subject: Medical-legal communications scenario

It's been a while since we've had a good legal scenario on here, so here's

one for y'all to discuss amongst yourselves.

You are a certified (or licensed) EMS provider (ECA, EMT, EMT-I, EMT-P, it

doesn't matter) who is fully credentialed as a 911 provider for your local

EMS

agency. You've recently been injured and have been assigned to light duty

at your dispatch center. You receive a call and begin applying your EMD

protocols. During the course of reading/applying the EMD protocols, you find

that

the pre-arrival instructions are contraindicated for your patient's actual

condition. (For example, the cards instruct your patient to lay down for a

respiratory condition when your patient actually has CHF.)

Since you're licensed/certified to practice to your level of EMS

certification, how do you reconcile your standard of care as an EMS provider

with your

obligation to follow the EMD instructions?

Would your answer differ if you were not EMS certified and were instead

working just as the countywide dispatcher for the sheriff, EMS service, and

fire

department?

-Wes Ogilvie, MPA, JD, LP

-Attorney/Licensed Paramedic

-Austin, Texas

**************It's Tax Time! Get tips, forms, and advice on AOL Money &

Finance. (http://money. <http://money.aol.com/tax?NCID=aolprf00030000000001>

aol.com/tax?NCID=aolprf00030000000001)

March 13, 2008

If you are working in dispatch are you not working as a dispatcher. If so,

then would you not have to act under the dispatch guidelines and not as a street

medic. Unless you already have approval to do other wise? I think from a leagle

point of view you would be far more protected by doing that that trying to go it

alone if you would.

Lawrence

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March 13, 2008

I agree with Mr. Stafford and I submit the following

for further discussion.

How about the person with the OJT injury being

credentialed as an EMD and a Medic (B,I,P, or LP).

Shouldn't that person practice under the higher

credential? Also, does the " Good Samaritan Act "

provide any protection for the Medic credential?

Respectfully submitted,

HM 2 Jon Beach, EMT-I

--- Bernie Stafford

wrote:

> Wes,

>

> Here is my take on this scenario.

>

> Since I am in the dispatch because of an injury, I

> am assuming that I am not

> EMD certified. Thus I am not going to be covered

> even if I use the " EMD

> protocols " . If I know that what the EMD card is

> recommending is wrong, I am

> responsible to practice at my level of training, the

> old what would a person

> of equal or like training do in the situation.

> Therefore I would NOT follow

> the EMD instructions in this case if I am sure that

> the patient is in CHF.

> Having a patient lie down that has CHF will only

> cause the patient, if you

> can get them to lie down, to become much worse.

>

> As far as non-medical following the EMD cards, they

> are left with little

> choice. If your agency uses the EMD cards, you have

> to follow the EMD

> protocols or your open yourself up to legal and

> possible disciplinary action

> for not following the EMD cards.

>

> I would like to see some independent research done

> on the EMD system and

> either validate the system or prove that the system

> does not work. Right now

> I don't know of any independent studies that have

> been done on the EMD

> system.

>

> Bernie Stafford EMTP

>

> _____

>

> From: texasems-l

> [mailto:texasems-l ] On

> Behalf Of ExLngHrn@...

> Sent: Wednesday, March 12, 2008 8:27 PM

> To: texasems-l

> Subject: Medical-legal communications

> scenario

>

> It's been a while since we've had a good legal

> scenario on here, so here's

> one for y'all to discuss amongst yourselves.

>

> You are a certified (or licensed) EMS provider (ECA,

> EMT, EMT-I, EMT-P, it

> doesn't matter) who is fully credentialed as a 911

> provider for your local

> EMS

> agency. You've recently been injured and have been

> assigned to light duty

> at your dispatch center. You receive a call and

> begin applying your EMD

> protocols. During the course of reading/applying the

> EMD protocols, you find

> that

> the pre-arrival instructions are contraindicated for

> your patient's actual

> condition. (For example, the cards instruct your

> patient to lay down for a

> respiratory condition when your patient actually has

> CHF.)

>

> Since you're licensed/certified to practice to your

> level of EMS

> certification, how do you reconcile your standard of

> care as an EMS provider

> with your

> obligation to follow the EMD instructions?

>

> Would your answer differ if you were not EMS

> certified and were instead

> working just as the countywide dispatcher for the

> sheriff, EMS service, and

> fire

> department?

>

> -Wes Ogilvie, MPA, JD, LP

> -Attorney/Licensed Paramedic

> -Austin, Texas

>

> **************It's Tax Time! Get tips, forms, and

> advice on AOL Money &

> Finance. (http://money.

> <http://money.aol.com/tax?NCID=aolprf00030000000001>

> aol.com/tax?NCID=aolprf00030000000001)

>

> [Non-text portions of this message have been

> removed]

>

> [Non-text portions of this message have been

> removed]

>

________________________________________________________________________________\

____

Looking for last minute shopping deals?

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March 13, 2008

When in dispatch there have been many times that I would have done or

said different if I would have been with the patient. I think thats

the key to remember. When a person calls for help, they are your

eyes, ears and your key to getting them help. Instructions as a

dispatcher for the caller are written so that even an idiot could do

it and understand it. When your sitting as a dispatcher your patch

might tell you other wise but the person that is calling is not a

medic. They don't have a patch and should not be given or expected to

do something that only a medic with training would do or tell them to

do after evalation. As a Medic your protocols are for when your with

the patient. As a dispatcher your protocols are specific for callers

calling in as the patent or for the patient.

I'm not sure what EMD protocols are being used in the cases below,

but if you really want to see some that make since look into the

National Academy EMD Protocols.

>

> > Wes,

> >

> > Here is my take on this scenario.

> >

> > Since I am in the dispatch because of an injury, I

> > am assuming that I am not

> > EMD certified. Thus I am not going to be covered

> > even if I use the " EMD

> > protocols " . If I know that what the EMD card is

> > recommending is wrong, I am

> > responsible to practice at my level of training, the

> > old what would a person

> > of equal or like training do in the situation.

> > Therefore I would NOT follow

> > the EMD instructions in this case if I am sure that

> > the patient is in CHF.

> > Having a patient lie down that has CHF will only

> > cause the patient, if you

> > can get them to lie down, to become much worse.

> >

> > As far as non-medical following the EMD cards, they

> > are left with little

> > choice. If your agency uses the EMD cards, you have

> > to follow the EMD

> > protocols or your open yourself up to legal and

> > possible disciplinary action

> > for not following the EMD cards.

> >

> > I would like to see some independent research done

> > on the EMD system and

> > either validate the system or prove that the system

> > does not work. Right now

> > I don't know of any independent studies that have

> > been done on the EMD

> > system.

> >

> > Bernie Stafford EMTP

> >

> > _____

> >

> > From: texasems-l

> > [mailto:texasems-l ] On

> > Behalf Of ExLngHrn@...

> > Sent: Wednesday, March 12, 2008 8:27 PM

> > To: texasems-l

> > Subject: Medical-legal communications

> > scenario

> >

> > It's been a while since we've had a good legal

> > scenario on here, so here's

> > one for y'all to discuss amongst yourselves.

> >

> > You are a certified (or licensed) EMS provider (ECA,

> > EMT, EMT-I, EMT-P, it

> > doesn't matter) who is fully credentialed as a 911

> > provider for your local

> > EMS

> > agency. You've recently been injured and have been

> > assigned to light duty

> > at your dispatch center. You receive a call and

> > begin applying your EMD

> > protocols. During the course of reading/applying the

> > EMD protocols, you find

> > that

> > the pre-arrival instructions are contraindicated for

> > your patient's actual

> > condition. (For example, the cards instruct your

> > patient to lay down for a

> > respiratory condition when your patient actually has

> > CHF.)

> >

> > Since you're licensed/certified to practice to your

> > level of EMS

> > certification, how do you reconcile your standard of

> > care as an EMS provider

> > with your

> > obligation to follow the EMD instructions?

> >

> > Would your answer differ if you were not EMS

> > certified and were instead

> > working just as the countywide dispatcher for the

> > sheriff, EMS service, and

> > fire

> > department?

> >

> > -Wes Ogilvie, MPA, JD, LP

> > -Attorney/Licensed Paramedic

> > -Austin, Texas

> >

> > **************It's Tax Time! Get tips, forms, and

> > advice on AOL Money &

> > Finance. (http://money.

> > <http://money.aol.com/tax?NCID=aolprf00030000000001>

> > aol.com/tax?NCID=aolprf00030000000001)

> >

> > [Non-text portions of this message have been

> > removed]

> >

> > [Non-text portions of this message have been

> > removed]

> >

>

______________________________________________________________________

______________

> Looking for last minute shopping deals?

> Find them fast with Yahoo! Search.

http://tools.search.yahoo.com/newsearch/category.php?category=shopping

>

March 14, 2008

I agree with this comment, the National Academy Protocols are thoroughly

researched, to prove not only if they work, but would they hold up in a

court room. I am of the opinion that Texas should mandate standardized EMD

protocols throughout the state. Furthermore, If you believe the protocol

would instruct you do perform a dangerous or inappropriate action, I submit,

you are on the incorrect protocol to begin with. Just as you would be if you

where on a truck.

>

> When in dispatch there have been many times that I would have done or

> said different if I would have been with the patient. I think thats

> the key to remember. When a person calls for help, they are your

> eyes, ears and your key to getting them help. Instructions as a

> dispatcher for the caller are written so that even an idiot could do

> it and understand it. When your sitting as a dispatcher your patch

> might tell you other wise but the person that is calling is not a

> medic. They don't have a patch and should not be given or expected to

> do something that only a medic with training would do or tell them to

> do after evalation. As a Medic your protocols are for when your with

> the patient. As a dispatcher your protocols are specific for callers

> calling in as the patent or for the patient.

>

> I'm not sure what EMD protocols are being used in the cases below,

> but if you really want to see some that make since look into the

> National Academy EMD Protocols.

>

> >

> > > Wes,

> > >

> > > Here is my take on this scenario.

> > >

> > > Since I am in the dispatch because of an injury, I

> > > am assuming that I am not

> > > EMD certified. Thus I am not going to be covered

> > > even if I use the " EMD

> > > protocols " . If I know that what the EMD card is

> > > recommending is wrong, I am

> > > responsible to practice at my level of training, the

> > > old what would a person

> > > of equal or like training do in the situation.

> > > Therefore I would NOT follow

> > > the EMD instructions in this case if I am sure that

> > > the patient is in CHF.

> > > Having a patient lie down that has CHF will only

> > > cause the patient, if you

> > > can get them to lie down, to become much worse.

> > >

> > > As far as non-medical following the EMD cards, they

> > > are left with little

> > > choice. If your agency uses the EMD cards, you have

> > > to follow the EMD

> > > protocols or your open yourself up to legal and

> > > possible disciplinary action

> > > for not following the EMD cards.

> > >

> > > I would like to see some independent research done

> > > on the EMD system and

> > > either validate the system or prove that the system

> > > does not work. Right now

> > > I don't know of any independent studies that have

> > > been done on the EMD

> > > system.

> > >

> > > Bernie Stafford EMTP

> > >

> > > _____

> > >

> > > From: texasems-l <texasems-l%40yahoogroups.com>

> > > [mailto:texasems-l <texasems-l%40yahoogroups.com>] On

> > > Behalf Of ExLngHrn@...

> > > Sent: Wednesday, March 12, 2008 8:27 PM

> > > To: texasems-l <texasems-l%40yahoogroups.com>

> > > Subject: Medical-legal communications

> > > scenario

> > >

> > > It's been a while since we've had a good legal

> > > scenario on here, so here's

> > > one for y'all to discuss amongst yourselves.

> > >

> > > You are a certified (or licensed) EMS provider (ECA,

> > > EMT, EMT-I, EMT-P, it

> > > doesn't matter) who is fully credentialed as a 911

> > > provider for your local

> > > EMS

> > > agency. You've recently been injured and have been

> > > assigned to light duty

> > > at your dispatch center. You receive a call and

> > > begin applying your EMD

> > > protocols. During the course of reading/applying the

> > > EMD protocols, you find

> > > that

> > > the pre-arrival instructions are contraindicated for

> > > your patient's actual

> > > condition. (For example, the cards instruct your

> > > patient to lay down for a

> > > respiratory condition when your patient actually has

> > > CHF.)

> > >

> > > Since you're licensed/certified to practice to your

> > > level of EMS

> > > certification, how do you reconcile your standard of

> > > care as an EMS provider

> > > with your

> > > obligation to follow the EMD instructions?

> > >

> > > Would your answer differ if you were not EMS

> > > certified and were instead

> > > working just as the countywide dispatcher for the

> > > sheriff, EMS service, and

> > > fire

> > > department?

> > >

> > > -Wes Ogilvie, MPA, JD, LP

> > > -Attorney/Licensed Paramedic

> > > -Austin, Texas

> > >

> > > **************It's Tax Time! Get tips, forms, and

> > > advice on AOL Money &

> > > Finance. (http://money.

> > > <http://money.aol.com/tax?NCID=aolprf00030000000001>

> > > aol.com/tax?NCID=aolprf00030000000001)

> > >

> > > [Non-text portions of this message have been

> > > removed]

> > >

> > > [Non-text portions of this message have been

> > > removed]

> > >

> >

> __________________________________________________________

> ______________

> > Looking for last minute shopping deals?

> > Find them fast with Yahoo! Search.

> http://tools.search.yahoo.com/newsearch/category.php?category=shopping

> >

>

March 14, 2008

I have kept quiet about this until now, preferring to see what the others

would say.

I now have some thoughts to share.

1. When you say " the National Academy Protocols are thoroughly researched, "

think carefully about what you're saying. Unless you have read and

evaluated all the research, you are on thin ground making such a statement.

True,

there are a number of research articles addressing dispatch and the EMD system,

but many of them are (1) written by Jeff Clawson, MD, the inventor of EMD, who

has a personal bias, (2) not printed in peer reviewed journals (EMS Mag and

JEMS are not peer reviewed in the sense that articles in JAMA are [and I write

for EMS Mag and serve on its editorial board], (3) many of them deal only with

cardiac arrest cases, and (4) the methodology of some of them is highly

questionable. All research must be viewed with skepticism as to bias,

methodology, and so forth.

2. It is dangerous to advise someone that " they would hold up in a

courtroom. " Nobody knows what will hold up until the time of trial and after

the

jury verdict is in. They may lend an expert witness some support for his

opinion that they are a safe and valid way to give pre-arrival instructions

[note,

many of the research articles do not deal with pre-arrival instructions nor

address the specific question Wes asked], but they are subject to attack.

3. The EMD system is a proprietary system that people buy. The contract,

I am told, states that you must follow them exactly or NAEMD will not come to

your rescue. That leaves plenty of wiggle room. Plus, no matter what EMS

says, you're still responsible for your own acts as a call-taker, a medic, and

a provider. NAEMD, unless it guarantees to indemnify and hold you and your

service harmless from ALL claims, judgments and liabilities (and I do not know

whether or not it does, not having seen its contracts) will not relieve you of

liability if you're found liable. I do not believe that it functions as an

insurance policy.

4. Therefore, the question is whether or not to follow boilerplace in all

instances or to use your common sense and medical judgment. The conversation

here has discussed that, but I submit there are no easy answers. In a legal

dispute, the question will be whether or not your actions were those of a

reasonable and prudent call-taker, taking into consideration all the unique

circumstances of the case. That will be determined by the jury.

5. Any set of protocols are only as good as the person interpreting them.

EMD is not a fool-proof system, and the research it touts does not show that

it's fool-proof. There is always a human element. Misinterpretation or a

mistake in following the algorhythms can cause problems; so can ignoring

information the patient or other caller tells you about the condition of the

patient

when giving advice.

My advice: Don't leave your common sense at home.

Gene G.

>

> I agree with this comment, the National Academy Protocols are thoroughly

> researched, to prove not only if they work, but would they hold up in a

> court room. I am of the opinion that Texas should mandate standardized EMD

> protocols throughout the state. Furthermore, If you believe the protocol

> would instruct you do perform a dangerous or inappropriate action, I submit,

> you are on the incorrect protocol to begin with. Just as you would be if you

> where on a truck.

>

> On 3/13/08, rasberrytwist381 <rasberrytwist381@rasberryt> wrote:

> >

> > When in dispatch there have been many times that I would have done or

> > said different if I would have been with the patient. I think thats

> > the key to remember. When a person calls for help, they are your

> > eyes, ears and your key to getting them help. Instructions as a

> > dispatcher for the caller are written so that even an idiot could do

> > it and understand it. When your sitting as a dispatcher your patch

> > might tell you other wise but the person that is calling is not a

> > medic. They don't have a patch and should not be given or expected to

> > do something that only a medic with training would do or tell them to

> > do after evalation. As a Medic your protocols are for when your with

> > the patient. As a dispatcher your protocols are specific for callers

> > calling in as the patent or for the patient.

> >

> > I'm not sure what EMD protocols are being used in the cases below,

> > but if you really want to see some that make since look into the

> > National Academy EMD Protocols.

> >

> > >

> > > > Wes,

> > > >

> > > > Here is my take on this scenario.

> > > >

> > > > Since I am in the dispatch because of an injury, I

> > > > am assuming that I am not

> > > > EMD certified. Thus I am not going to be covered

> > > > even if I use the " EMD

> > > > protocols " . If I know that what the EMD card is

> > > > recommending is wrong, I am

> > > > responsible to practice at my level of training, the

> > > > old what would a person

> > > > of equal or like training do in the situation.

> > > > Therefore I would NOT follow

> > > > the EMD instructions in this case if I am sure that

> > > > the patient is in CHF.

> > > > Having a patient lie down that has CHF will only

> > > > cause the patient, if you

> > > > can get them to lie down, to become much worse.

> > > >

> > > > As far as non-medical following the EMD cards, they

> > > > are left with little

> > > > choice. If your agency uses the EMD cards, you have

> > > > to follow the EMD

> > > > protocols or your open yourself up to legal and

> > > > possible disciplinary action

> > > > for not following the EMD cards.

> > > >

> > > > I would like to see some independent research done

> > > > on the EMD system and

> > > > either validate the system or prove that the system

> > > > does not work. Right now

> > > > I don't know of any independent studies that have

> > > > been done on the EMD

> > > > system.

> > > >

> > > > Bernie Stafford EMTP

> > > >

> > > > _____

> > > >

> > > > From: texasems-l@yahoogrotexasem <texasems-l%texasems-l%<wbtex>

> > > > [mailto:texasems-l@yahoogrotexasem <texasems-l%texasems-l%<wbtex>] On

> > > > Behalf Of ExLngHrn@...

> > > > Sent: Wednesday, March 12, 2008 8:27 PM

> > > > To: texasems-l@yahoogrotexasem <texasems-l%texasems-l%<wbtex>

> > > > Subject: Medical-legal communications

> > > > scenario

> > > >

> > > > It's been a while since we've had a good legal

> > > > scenario on here, so here's

> > > > one for y'all to discuss amongst yourselves.

> > > >

> > > > You are a certified (or licensed) EMS provider (ECA,

> > > > EMT, EMT-I, EMT-P, it

> > > > doesn't matter) who is fully credentialed as a 911

> > > > provider for your local

> > > > EMS

> > > > agency. You've recently been injured and have been

> > > > assigned to light duty

> > > > at your dispatch center. You receive a call and

> > > > begin applying your EMD

> > > > protocols. During the course of reading/applying the

> > > > EMD protocols, you find

> > > > that

> > > > the pre-arrival instructions are contraindicated for

> > > > your patient's actual

> > > > condition. (For example, the cards instruct your

> > > > patient to lay down for a

> > > > respiratory condition when your patient actually has

> > > > CHF.)

> > > >

> > > > Since you're licensed/certified to practice to your

> > > > level of EMS

> > > > certification, how do you reconcile your standard of

> > > > care as an EMS provider

> > > > with your

> > > > obligation to follow the EMD instructions?

> > > >

> > > > Would your answer differ if you were not EMS

> > > > certified and were instead

> > > > working just as the countywide dispatcher for the

> > > > sheriff, EMS service, and

> > > > fire

> > > > department?

> > > >

> > > > -Wes Ogilvie, MPA, JD, LP

> > > > -Attorney/Licensed Paramedic

> > > > -Austin, Texas

> > > >

> > > > ************ **************It's Tax Time! Ge

> > > > advice on AOL Money &

> > > > Finance. (http://money.

> > > > <http://money.http://moneyhttp://money.<wbhttp://mo>

> > > > aol.com/tax? aol.com/tax?<wb aol.com/t

> > > >

> > > > [Non-text portions of this message have been

> > > > removed]

> > > >

> > > > [Non-text portions of this message have been

> > > > removed]

> > > >

> > >

> > ____________ ________ ________ ________ ________ ________

> > ____________ _

> > > Looking for last minute shopping deals?

> > > Find them fast with Yahoo! Search.

> > http://tools.http://tools.http://tools.http://tohttp://tools.http://t

> > >

> >

>

March 14, 2008

I would think the correct thing to do would be to follow your

training. Since patient well being is our primary concern, I would

hate to give wrong information or wrong treatment for something that

could have been as simple as a typo or mistake in the protocol book.

In short, provide the correct treatment, DOCUMENT IT, and bring it up

to your medical director or whoever in your department is responsible

for making protocol changes ASAP.

The other alternative is to get online medical direction but I am not

sure if that is fesiable for a dispatcher since they need immediate

information.

Quinten

NREMT-P

Fire Engineer

>

> It's been a while since we've had a good legal scenario on here, so

here's

> one for y'all to discuss amongst yourselves.

>

> You are a certified (or licensed) EMS provider (ECA, EMT, EMT-I,

EMT-P, it

> doesn't matter) who is fully credentialed as a 911 provider for

your local EMS

> agency. You've recently been injured and have been assigned to

light duty

> at your dispatch center. You receive a call and begin applying

your EMD

> protocols. During the course of reading/applying the EMD protocols,

you find that

> the pre-arrival instructions are contraindicated for your patient's

actual

> condition. (For example, the cards instruct your patient to lay

down for a

> respiratory condition when your patient actually has CHF.)

>

> Since you're licensed/certified to practice to your level of EMS

> certification, how do you reconcile your standard of care as an EMS

provider with your

> obligation to follow the EMD instructions?

>

> Would your answer differ if you were not EMS certified and were

instead

> working just as the countywide dispatcher for the sheriff, EMS

service, and fire

> department?

>

> -Wes Ogilvie, MPA, JD, LP

> -Attorney/Licensed Paramedic

> -Austin, Texas

>

> **************It's Tax Time! Get tips, forms, and advice on AOL

Money &

> Finance. (http://money.aol.com/tax?NCID=aolprf00030000000001)

>

March 14, 2008

Yes, and many people are of the opinion that it's an iron-clad, fool-proof

system, that if you use it Clawson will defend you and always win, and so forth.

The truth is that he has often been successful in defending mistakes, but

we do not know about all the claims that have been filed, nor do we know about

the ones that were settled without litigation.

I have been reading the research articles cited in the NAED website, and they

actually do not do much to address the question in Wes's scenario.

Further, local medical directors may modify the algorhythms to fit local

needs; so in the given situation, where there was a CHF patient as I recall, and

the question was whether or not he should be advised to lie down, or whether a

3rd party caller should be advised to make him lie down, what does MPD

actually say about that situation, and what do local protocols say?

Further, there may be a difference in liability if EMD is being used in a

free-standing call center, or one that is run by another agency, such as a

county

sheriff, that is separate from the EMS entity. Consider, for example, such

a center that uses employees from EMS to staff the EMS portion of the center

as call-takers.

There are plenty of nuances that can change the issues and outcomes with EMD.

In my opinion, one need not leave his medical judgment outside the door of

the dispatch center. It has been said that the more medical training, the

worse the EMD algothythms work, and that is probably true, because the EMS

system

assumes rigid adherence to the plan. People with no medical training might

follow the EMD rules better. However, that does not address the accuracy of

the system's assessment of a patient's problems and the medical advice given

them.

Attempts to have RNs attempt telephone triage have been spectacular failures

(remember the famous Dallas case where a nurse refused to send an ambulance

for a heart patient and the patient died).

At best, telephone triage is hit and miss, and pre-arrival instructions may

be difficult, but if a patient tells me he can't breathe because of pulmonary

edema (or I figure that out by questioning) , the last thing I'm going to do is

tell him to lie down, regardless of what a recipe book says. Of course,

even if I told him to do so, he wouldn't do it, because he cannot breathe lying

down. Hell, you couldn't make him lie down if you held a shotgun on him.

Gene G.

>

> >>EMD is not a fool-proof system, and the research it touts does not

> show that

> it's fool-proof.<<

>

> As to determining patient acuity, only as accurate as a coin flip on

> half its protocols, and considerably less than accurate as a coin flip

> on the other half.

>

> That's reassuring, ain't it?

>

> --

> Grayson, CCEMT-P

> www.kellygrayson. ww

>

**************

It's Tax Time! Get tips, forms, and advice on AOL Money & amp;

Finance.

(http://money.aol.com/tax?NCID=aolprf00030000000001)

March 14, 2008

>>EMD is not a fool-proof system, and the research it touts does not

show that

it's fool-proof.<<

As to determining patient acuity, only as accurate as a coin flip on

half its protocols, and considerably less than accurate as a coin flip

on the other half.

That's reassuring, ain't it?

--

Grayson, CCEMT-P

www.kellygrayson.com

March 14, 2008

This is the sort of dialog we need. Dudley, you present some very good

points. Please read down and I will engage you in some questions below.

GG

>

> I'll weigh in just a bit...

>

> Having over 8 years of EMD certification and experience under my belt in a

> previous system, I can make a couple of points.

>

> 1.? EMD requires that you ask the questions verbatim, in the order they are

> written...after that...the remainder is up to the agency's medical director.?

>

What were the written parameters for answering questions? When do the EMD

questions stop and the system questions begin? Where is the dividing point

between EMD's questions and the local service's questions? Is that written

anywhere or just up for grabs?

> In the system I was in, we answered an average of 600 requests for service

> a day.? EMD was provided by Paramedics who had a minimum of 2 years

> experience in the system (4 shifts a week, avg of 8 pt contacts a shift,

(>3300 pt

> contacts) and were not only EMD trained but had completed a thorough

call-taking

> training program.?

>

What was the " thorough call-taking training program? " Was it a part of the

EMD system, or did your agency develop it? And if system developed, what went

into the design of the call-taking training program?

> After asking the EMD questions as written, we often gave important

> information.3300 pt contacts) and were not only EMD trained but had completed

a

> thorough call-taking training program.? After asking the EMD questions as

written,

> we often gave important information.?

>

Where did the " important information " come from? Was it ad hoc advice given

by the experienced paramedics, or did the algorithm lead the call-taker to

another set of questions and responses?

How would you have defended your " important information " items that were

recorded by your system and made available to the plaintiffs in a claim? Was

there P & P to support them, protocols to support them, or were you allowing your

experienced medics to use common sense in dealing with the perceived situation?

> As to this particular scenario, EMD cards for difficulty breathing all

> state to encourage the caller to have the patient assume a position of comfort

> and that sitting up is usually more comfortable than laying down.? We also

> routinely told CHF pt's to not only sit up but to dangle their legs off the

couch

> or bed.? In addition, the pre-arrival instructions are extremely well

> crafted and I for one can tell you I have delivered MANY more babies over the

phone

> with the lay public than I ever caught on the truck.? Overall, it is very

> impressive, works very

>

Well, I would ask you, did you rely upon your personal experience in

" birthing babies " to give the advice or just read the instructions? Or was it

a

combination of both? If you had never had any training in emergency

deliveries,

would your EMD instructions have been adequate, or did you have to rely upon

your experience to help you talk the people through the delivery?

>

> 2.? In this system described above, there was a desire to use EMD to

> determine which calls received an emergency response and which calls would

receive a

> non-emergency response.? Before this commenced, 100% of the calls received

> (BTW, we did EMD on all calls, not just 911...so nursing homes, doctor

> offices, etc all were triaged) over 3 months were reviewed to insure 100% of

the

> questions were answered, based upon these answers, 100% of the determinants

were

> correct according to the answers received, and then these were cross

> referenced to patient care reports to see what was found upon arrival, what

> interventions were done, how the patient was transported, and what the final

field

> impression was by both the fire and transport crews.? Lastly, X% (can't

> remember how many) were followed up by getting diagnosis and outcome from the

> receiving Emergency Room.? What we learned was that if we followed the cards

> verbatim, and across the board said " Alpha and Bravo get a non-emergency

response

> and Charlie and Delta get an emergency response " we would have missed some

> patients our medical direction felt should get an emergency response.?

>

So did he involve EMD with that or simply make changes based upon his own

experience? Was the inadequacy of EMD ever communicated to them, and if so

what

was their response?

> So, we changed a handful of determinants based upon what we found in our

> community and turned the system on with good success.?

>

Judged by what? In whose opinion? Did you write this up as a study and

get it published? How can you say that it improved the system? If I were

writing an article about this, what could I cite as your conclusions about this?

> After the fact, call-takers continued to have a high percentage of their

> EMD evaluated and scored, which was reflected on evaluations and raises.?

>

Evaluated by whom? Scored on what basis? What were the parameters of your

evaluations? What were the biases? What were the rules? Did you have

them in P & P, or were they informal?

Regardless of the answers to those questions, did your call-takers improve,

stay the same, or decline in their abilities to pinpoint the problem and give

the right advice? And how did you arrive at your answer?

>

> Now, for my soapbox...pre- Now, for my soapbox...pre-arrival

> instructions should be mandatory for every call center (or we should develop

regional

> PAI centers).? The public expects it, deserves

>

NO DISPUTE HERE! It should be mandatory.

>

> Towards EMD, the primary purpose of EMD is to have a system to determine

> which calls do and DO NOT need an emergency response.? Since EMS alone is

> killing 1 person a week and seriously injuring 10 people a day in ambulance

> accidents across the nation, it is criminal that all of us are not working to

reduce

> the numbers of calls we respond emergency to.?

>

When you say EMS is killing 1 person a week, you mean from motor vehicle

collisions, don't you? I think that's what the information shows. And yes, I

agree that it is nothing short of criminal that " all of us " are not working to

reduce the numbers of calls we respond emergency to. But I also think that

we do not emphasize safe driving procedures in our initial paramedic classes,

and most employers do not ever address driving to their employees. That

should not be, but it is.

>

> When doing this, we can do it one of two ways...we can pull things out of

> our hats....allow the medics on the trucks to do it based upon what they are

> told by dispatch.... When doing this, we can do it one of two ways...we can

> pull things out of our hats....allow the medics on the trucks to do it based

> upon what they are told by dispatch....who, if not following a set

> protocol, may or may not be asking appropriate questions to glean the

information

> that crews are using to make this decision, OR we can adopt a uniform set of

> pre-developed protocols that have been systematically improved and refined for

> over 30 years, that demands a se When doing this, we can do it one of two

> ways...we can pull things out of our hats....allow the medics on the trucks to

do

> it based upon what they are told by dispatch....who, if not following a

> set protocol, may or may not be asking appr

>

Dudley, in spite of the fact that EMS has been in existence for over 30

years, there is NO valid research pointing to its efficacy. Most of the

" research " tending to support it is anecdotal, or in articles that were not peer

reviewed and published in recognized journals (JEMS and EMS are not

peer-reviewed

journals in the sense that JAMA is). There is basically no support for the

proposition that EMD actually improves patient outcomes. Can you challenge

that? If so, please do.

> As I always do, we say EMD doesn't work or isn't accurate...I' As I always

> do, we say EMD doesn't work or isn't accurate...I've explained why I

> believe it is...I would like to see the research or methodol

>

> Have a great weekend everyone.

>

> Dudley

>

> Re: Re: Medical-legal communications scenario

>

> >>EMD is not a fool-proof system, and the research it touts does not

> show that

> it's fool-proof.<<

>

> As to determining patient acuity, only as accurate as a coin flip on

> half its protocols, and considerably less than accurate as a coin flip

> on the other half.

>

> That's reassuring, ain't it?

>

> --

> Grayson, CCEMT-P

> www.kellygrayson. ww

>

March 14, 2008

I'll weigh in just a bit...

Having over 8 years of EMD certification and experience under my belt in a

previous system, I can make a couple of points.

1.? EMD requires that you ask the questions verbatim, in the order they are

written...after that...the remainder is up to the agency's medical director.? In

the system I was in, we answered an average of 600 requests for service a day.?

EMD was provided by Paramedics who had a minimum of 2 years experience in the

system (4 shifts a week, avg of 8 pt contacts a shift, (>3300 pt contacts) and

were not only EMD trained but had completed a thorough call-taking training

program.? After asking the EMD questions as written, we often gave important

information.? As to this particular scenario, EMD cards for difficulty breathing

all state to encourage the caller to have the patient assume a position of

comfort and that sitting up is usually more comfortable than laying down.? We

also routinely told CHF pt's to not only sit up but to dangle their legs off the

couch or bed.? In addition, the pre-arrival instructions are extremely well

crafted and I for one can tell you I have delivered MANY more babies over the

phone with the lay public than I ever caught on the truck.? Overall, it is very

impressive, works very well, and when implemented correctly, provides relevant,

and appropriate information while helping to insure that decisions made from the

information gleaned err to the safe side for patients.

2.? In this system described above, there was a desire to use EMD to determine

which calls received an emergency response and which calls would receive a

non-emergency response.? Before this commenced, 100% of the calls received (BTW,

we did EMD on all calls, not just 911...so nursing homes, doctor offices, etc

all were triaged) over 3 months were reviewed to insure 100% of the questions

were answered, based upon these answers, 100% of the determinants were correct

according to the answers received, and then these were cross referenced to

patient care reports to see what was found upon arrival, what interventions were

done, how the patient was transported, and what the final field impression was

by both the fire and transport crews.? Lastly, X% (can't remember how many) were

followed up by getting diagnosis and outcome from the receiving Emergency Room.?

What we learned was that if we followed the cards verbatim, and across the board

said " Alpha and Bravo get a non-emergency response and Charlie and Delta get an

emergency response " we would have missed some patients our medical direction

felt should get an emergency response.? So, we changed a handful of determinants

based upon what we found in our community and turned the system on with good

success.? After the fact, call-takers continued to have a high percentage of

their EMD evaluated and scored, which was reflected on evaluations and raises.?

Now, for my soapbox...pre-arrival instructions should be mandatory for every

call center (or we should develop regional PAI centers).? The public expects it,

deserves it, and they are a great tool.?

Towards EMD, the primary purpose of EMD is to have a system to determine which

calls do and DO NOT need an emergency response.? Since EMS alone is killing 1

person a week and seriously injuring 10 people a day in ambulance accidents

across the nation, it is criminal that all of us are not working to reduce the

numbers of calls we respond emergency to.?

When doing this, we can do it one of two ways...we can pull things out of our

hats....allow the medics on the trucks to do it based upon what they are told by

dispatch....who, if not following a set protocol, may or may not be asking

appropriate questions to glean the information that crews are using to make this

decision, OR we can adopt a uniform set of pre-developed protocols that have

been systematically improved and refined for over 30 years, that demands a set

method of asking the questions with local medical control decisions, based upon

the uniform questions being asked, determining what is responded to emergency or

non-emergency.? As for " what will hold up in court " I sleep much better at night

knowing my folks in dispatch are following a set protocol each time 911?rings

(just like the medics on the streets) and decisions are then made off of this

consistent process.?

As I always do, we say EMD doesn't work or isn't accurate...I've explained why I

believe it is...I would like to see the research or methodology used to

determine it is almost or much worse than a coin flip...

Have a great weekend everyone.

Dudley

Re: Re: Medical-legal communications scenario

>>EMD is not a fool-proof system, and the research it touts does not

show that

it's fool-proof.<<

As to determining patient acuity, only as accurate as a coin flip on

half its protocols, and considerably less than accurate as a coin flip

on the other half.

That's reassuring, ain't it?

--

Grayson, CCEMT-P

www.kellygrayson.com

March 15, 2008

Thanks for this illuminating information. I had not disclosed this, but I

went through the EMD course years ago and was certified, so I have some

knowledge of the process.

My caveat is for folks not to think that MPD is a guaranteed fool-proof

system. It is only as good as those who use it, and it is fairly complex to

get

to know completely.

I am pleased that in your former system communicators were allowed to add

questions and so forth. Otherwise, we could have software programs that would

answer the phone and ask the questions, like those maddening phone-answering

programs that you have to get through to talk to a real human (I'm sorry. I

didn't hear you. Can you speak louder? Did you say, " I want a milkshake? "

Thank you. An ambulance will be sent immediately. " )

On the Ohio driver, I was quoting from another site. I don't know what Ohio

law provides but I accept what the site said. Texas is similar in that it

does not require a full stop for emergency vehicles. If it did, every police

officer in the state would be paying fines every day. Cops are the worst

violators of the speed laws and, of course, they are never called on the carpet

until they kill somebody.

GG

>

> Gene,

>

> Let me see if I can answer some of these...

>

> 1.? Your first question was about the parameters for answering questions...

> 1.? Your first question was about the parameters for answering que 1.? Your

> first question was about the parameters for answering questions...the

> parameters for answering questions were pretty straightforward...ask the

> case entry questions (age, conscious, breathing) then based upon the stated

> problem from the caller, ask EVERY question on that particular card...in the

> order they are presented (in my day, it was cards, now it is on computers and

> you only get one question at a time...helps prevent people from skipping.?

Then

> we were allowed to add any additional information, from our experience, and

> in some cases, from our SOP's and protocols.? (Sitting up, legs hanging down,

> etc.)? Nothing could be asked additionally, until all EMD questions were

> asked.? And remember, a large % of the time, we were merely askin 1.? Your

first

> question was about the parameters for answering questions...the

> parameters for answe

>

> 2.? EMD certification was a part of our call-taking training and you could

> not answer phones until you got it.? The remainder of the training program

> involved listening in on calls, being mentored through the process, and then

> being allowed to fly solo...it followed many of the same principles of our

> agency's FTO program...realizing that training and supervision in a comm ctr

is

> much different than in the field due to proximity, and direct oversight.

>

> 3.? On the important information, as I stated in #1 above, it was a

> combination. 3.? On the important information, as I stated in #1 above, it was

a

> combination.? One of the primary reasons we required experienced

paramedics,

> was to allow them to use their common sense in helping the caller in

> situations not addressed by pre-arrival instructions (CHF example, etc).? A

> particular call I still remember today is a call for a sick female.? She was a

1st

> party caller and I remember that after asking the EMD questions, before I

> disconnected, something just didn't add up.? She seemed very emotional for

being

> " sick " so I asked her if she was home alone, if the door was unlocked, and

> then she sounded like she was crying.? When asked, she said she was...then she

> admitted she had overdosed and was trying to kill herself.? My experience led

> me to ask " are there any weapons in the house " to which she admitted she had

> a gun.? I, of course, asked " where is the gun? " to which she answered " in my

> lap " .? Nothing here changed the

>

> 4.? On the instructions, we were required to read the instructions as

> written...and I might add that is because they are written to be read by

> non-medically trained personnel to non-medically trained personnel.? In my

opinion, the

> instructions are exceptional. 4.? On the instructions, we were required to

> read the instructions as written...and I might add that is because they are

> written to be read by non-medically trained personnel to non-medically trained

> personnel.? In my opinion, the instructions are exceptional.? They are

> very clear, and really allow you to walk a lay-person through a stressful

> event they probably n 4.? On the instructions, we were required to read the

> instructions as written...and I might add that is because they are written to

be

> read by no

>

> 5.? On us making changes, we did work with EMD, but the changes we made were

> in relation to what we would respond emergency or non-emergency to because

> we elected to not say an Alpha or Charlie determinant would always be

> responded to emergency.? We didn't change what the questions led to, just

that, for

> example, Card 12 is an emergency response for Bravo through Delta responses,

> but 10 of the others are emergency on only Charlies and Deltas....or on Card

> 12, Bravo 3 (each determinant had several things under them that signified the

> answers led to that determinant) was emergency but the remainder of the

> Bravo's were not....hope I didn't lose anyone here.

>

> 6.? On the " success " question, I used this word because we continued to

> elicit feedback on our EMD and what medics found when they arrived on scene,

as

> well as monitoring transport modes and field impressions as a secondary QI

> method on our EMD.? These numbers were minimal, and trust me, people calling a

> complaint hot-line was not an issue in this system.? Although I am not aware

> of anyone publishing any of this, I do know a poster presentation was done on

> the work leading up to us beginning minimizing our emergency responses, I am

> not sure where, although I am certain it could have been at the NAEMD annual

> conference.. 6.? On the " success " question, I used this word because we

> continued to elicit feedback on our EMD and what medics f

>

> 7.? Our EMD was evaluated (over 50% of our calls) based upon a QI process

> that held many objective (and a few subjective) criteria.? Such as, were the

> case entry questions asked and in order?? Was the correct complain card used

> based upon what the caller stated?? Were the questions on the card asked

> correctly and in the order presented?? Were the general directions given the

caller

> (turn a light on, have someone wave down the ambulance, open the door, call

> back if they get any worse, etc).? If PAI was done, were the instructions

> given in the order presented?? Were they read verbatim?? Etc.? The subjective

> criteria were related to techniques to get the caller to answer questions,

calm

> down if upset, etc.? The majority of our call-takers improved to greater

> than 97% in following the EMD process.? For us, since this was a promotion

from

> the field, if improvement was not seen, this was used to move medics back to

> the field.

>

> 8.? Yes...1 person a week in EMS Vehicle accidents.? I have no disagreements

> with you on these statements, but on your other post regarding the Ohio EMT

> ticketed for running the red-light... 8.? Yes...1 person a week in EMS

> Vehicle accidents.? I have no disagreements with you on these statements, but

on

> your other post regarding the Ohio EMT ticketed for running the red-light...<

> wbr>I

>

> 9.? I never said it improved patient outcomes, but there are many things in

> EMS operations that cannot be tied to patient outcomes (how does stopping at

> a red-light enroute to?a call improve outcomes,?or using one type of motor

> oil over another, or choosing an?one ambulance manufacturer over another...but

> they are all critical to efficient and successful operations)? 9.? I never

> said it improved patient outcomes, but there are many things in EMS operations

> that cannot be tied to patient outcomes (how does stopping

>

> NOW all this being said, the system I described was in another life...in my

> current system we are implementing this with PD dispatchers in an agency that

> I do not have direct oversight or supervision of...so, more to come in

> another chapter?of the " Life of Dudley " novel.?

>

> Dudley

>

> Re: Re: Medical-legal communications scenario

> >

> > >>EMD is not a fool-proof system, and the research it touts does not

> > show that

> > it's fool-proof.<<

> >

> > As to determining patient acuity, only as accurate as a coin flip on

> > half its protocols, and considerably less than accurate as a coin flip

> > on the other half.

> >

> > That's reassuring, ain't it?

> >

> > --

> > Grayson, CCEMT-P

> > www.kellygrayson. ww

> >

March 15, 2008

Gene,

Let me see if I can answer some of these...

1.? Your first question was about the parameters for answering questions...the

parameters for answering questions were pretty straightforward...ask the case

entry questions (age, conscious, breathing) then based upon the stated problem

from the caller, ask EVERY question on that particular card...in the order they

are presented (in my day, it was cards, now it is on computers and you only get

one question at a time...helps prevent people from skipping.? Then we were

allowed to add any additional information, from our experience, and in some

cases, from our SOP's and protocols.? (Sitting up, legs hanging down, etc.)?

Nothing could be asked additionally, until all EMD questions were asked.? And

remember, a large % of the time, we were merely asking additional questions,

based upon what you heard while asking EMD questions. (i.e. patient is reported

unconscious, but you hear talking in background...who is that, can they go

outside and wave down paramedics while I tell you how to help the patient, etc)

2.? EMD certification was a part of our call-taking training and you could not

answer phones until you got it.? The remainder of the training program involved

listening in on calls, being mentored through the process, and then being

allowed to fly solo...it followed many of the same principles of our agency's

FTO program...realizing that training and supervision in a comm ctr is much

different than in the field due to proximity, and direct oversight.

3.? On the important information, as I stated in #1 above, it was a

combination.? One of the primary reasons we required experienced paramedics, was

to allow them to use their common sense in helping the caller in situations not

addressed by pre-arrival instructions (CHF example, etc).? A particular call I

still remember today is a call for a sick female.? She was a 1st party caller

and I remember that after asking the EMD questions, before I disconnected,

something just didn't add up.? She seemed very emotional for being " sick " so I

asked her if she was home alone, if the door was unlocked, and then she sounded

like she was crying.? When asked, she said she was...then she admitted she had

overdosed and was trying to kill herself.? My experience led me to ask " are

there any weapons in the house " to which she admitted she had a gun.? I, of

course, asked " where is the gun? " to which she answered " in my lap " .? Nothing

here changed the outcome of the patient, but it did potentially change the

outcome for the responders.

4.? On the instructions, we were required to read the instructions as

written...and I might add that is because they are written to be read by

non-medically trained personnel to non-medically trained personnel.? In my

opinion, the instructions are exceptional.? They are very clear, and really

allow you to walk a lay-person through a stressful event they probably never

dreamed about handling (including helping kids deliver their brother or sister

or helping a lady deliver her child on her own).? We were allowed to again,

interject additional information based upon what we had gleaned or been told

while providing instructions.? Things like getting mother's off the toilet,

having drunks stop trying CPR when their drunk partner is screaming in the

background to stop, etc.

5.? On us making changes, we did work with EMD, but the changes we made were in

relation to what we would respond emergency or non-emergency to because we

elected to not say an Alpha or Charlie determinant would always be responded to

emergency.? We didn't change what the questions led to, just that, for example,

Card 12 is an emergency response for Bravo through Delta responses, but 10 of

the others are emergency on only Charlies and Deltas....or on Card 12, Bravo 3

(each determinant had several things under them that signified the answers led

to that determinant) was emergency but the remainder of the Bravo's were

not....hope I didn't lose anyone here.

6.? On the " success " question, I used this word because we continued to elicit

feedback on our EMD and what medics found when they arrived on scene, as well as

monitoring transport modes and field impressions as a secondary QI method on our

EMD.? These numbers were minimal, and trust me, people calling a complaint

hot-line was not an issue in this system.? Although I am not aware of anyone

publishing any of this, I do know a poster presentation was done on the work

leading up to us beginning minimizing our emergency responses, I am not sure

where, although I am certain it could have been at the NAEMD annual

conference...because back in the early 90's the prevalence of EMS types doing

something like this at other places was much lower.

7.? Our EMD was evaluated (over 50% of our calls) based upon a QI process that

held many objective (and a few subjective) criteria.? Such as, were the case

entry questions asked and in order?? Was the correct complain card used based

upon what the caller stated?? Were the questions on the card asked correctly and

in the order presented?? Were the general directions given the caller (turn a

light on, have someone wave down the ambulance, open the door, call back if they

get any worse, etc).? If PAI was done, were the instructions given in the order

presented?? Were they read verbatim?? Etc.? The subjective criteria were related

to techniques to get the caller to answer questions, calm down if upset, etc.?

The majority of our call-takers improved to greater than 97% in following the

EMD process.? For us, since this was a promotion from the field, if improvement

was not seen, this was used to move medics back to the field.

8.? Yes...1 person a week in EMS Vehicle accidents.? I have no disagreements

with you on these statements, but on your other post regarding the Ohio EMT

ticketed for running the red-light...I think state law should read that

ambulances and fire-trucks can proceed through red-lights and stop signs ONLY

AFTER coming to a complete stop...then the " due regard " statement added onto the

end.

9.? I never said it improved patient outcomes, but there are many things in EMS

operations that cannot be tied to patient outcomes (how does stopping at a

red-light enroute to?a call improve outcomes,?or using one type of motor oil

over another, or choosing an?one ambulance manufacturer over another...but they

are all critical to efficient and successful operations)?I was merely

challenging 's statements that it was only 50-50 on the information it

provided.? I know from my experience, that is not accurate.?

NOW all this being said, the system I described was in another life...in my

current system we are implementing this with PD dispatchers in an agency that I

do not have direct oversight or supervision of...so, more to come in another

chapter?of the " Life of Dudley " novel.?

Dudley

Re: Re: Medical-legal communications scenario

>

> >>EMD is not a fool-proof system, and the research it touts does not

> show that

> it's fool-proof.<<

>

> As to determining patient acuity, only as accurate as a coin flip on

> half its protocols, and considerably less than accurate as a coin flip

> on the other half.

>

> That's reassuring, ain't it?

>

> --

> Grayson, CCEMT-P

> www.kellygrayson. ww

>

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Medical-legal communications scenario

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