Re: Legal analysis of NTG vs. 12-lead

[Guest guest]

Yes.

The protocols are evidence of what is " reasonable and prudent " but they are

not infallible. If the protocols are bad, an argument can be made that the

system and the medical director have failed the standard of care test.

The protocols are the first thing I look at when I'm reviewing a case. I

look to see if they are current, meet recognized standards, and if they were

followed. Failure to follow one's own protocols are the proverbial kiss of

death.

But I also look to see if protocols are consistent with national guidelines,

the AHA guidelines in cardiac care. There is wiggle room within those

standards, but if a service isn't carrying ANY of the recommended drugs or

devices,

then there is a big problem

GG

>

> Gene,

>

> Although Wes didn't bring it up, we can't get away from it...it is the

> proverbial Pineapple.

>

> What does the protocols you are working under say?? To me the answer to

> Wes's question is what does the EMS System the FRO is working under (or basic

> transport provider) instruct them to do through protocol?? This is the answer

> and if the protocol doesn't make sense, then we need to work to update the

> protocol based upon the current practice and science so that it reflects the

most

> prudent way to perform based upon the expectations of the community.

>

> In our system, we have 8 different first responder agencies.? All of them

> work under our protocols and we have addressed this in a number of ways based

> upon the agency that is on-scene.? We have a number of FRO's that are equipped

> in a variety of ways...so our EMT-Basic protocol first of all asks our

> EMT-Basics to perform a 12-lead prior to administering NTG if they have a

device

> on scene that can do it.? This allows us to have a pre-treatment 12-lead, even

> if we have no advanced providers on scene.? Also,?if it says " ***ACUTE MI

> SUSPECTED*** In our system, we have 8 different first responder agencies.? All

> of th

>

> Either way, our EMT-Basics give NTG based upon the guidelines in our

> protocols... Either way, our EMT-Basics give NTG based upon the guidelines in

our

> protocols...<wbr>and those are built in an attempt to provide a

>

> Dudley

>

> Legal analysis of NTG vs. 12-lead

>

> We've been juggling apples, oranges, grapefruit, and tomatoes here.

>

> Let's try to sort this out from a legal point of view.

>

> First, the first rule of practice is to do that which a reasonable and

> prudent [choose one (FR)(EMT)(EMT- prudent [cho prudent [choose prudent

> [choose o

> level of education, training, and experience, would do in the same or

> similar

> circumstances.

>

> And keep in mind that the critical point may not be what you KNOW but what a

> reasonable and prudent medic OUGHT TO KNOW.

>

> So, what is reasonable and prudent for a FR to do with NTG? Depends on

> several things.

>

> First, let's take the situation where the patient has a prescription for NTG

> and has some with her. Can the FR assist her in taking it? In that case the

> FR becomes the patient's surrogate and is really operating under the

> patient's prescription. However, the FR does not stand in parity with the

> patient

> most of the time, since the FR has greater medical knowledge than the

> patient,

> and what is

> reasonable and prudent for a medically trained person is different from that

> of a layperson. So, the FR must first assess the patient to the extent of

> his capability, education, training, experience, and protocols, and then

> determine whether or not to give the NTG. If the patient croaks, the FR will

> be

> held only to the standard of care applicable to him.

>

> So all the stuff about waiting on the ALS folks is beside the point. Each

> level practices at his own standard of care. It might be reasonable and

> prudent for an EMT to give the NTG based upon his assessment, but not for

> the

> Paramedic. The EMT is not held to the standard of the Paramedic unless he

> has

> advanced training and education, special permission from medical control,

> and so

> forth. This will be highly dependent on state rules and regulations.

>

> Now, let's take the Paramedic. The Paramedic operates at a higher standard

> of care than the EMT. Therefore, what is reasonable and prudent for the

> Paramedic may be far different from what is reasonable and prudent for the

> EMT.

> Paramedics should know about coronary artery occlusions and how to spot them

> on a 12-lead. Paramedics should know that NTG has a cautionary use in

> patients with right ventricular infarcts. Therefore, it is reasonable and

> prudent

> that the Paramedic obtain a 12-lead if possible before administering a

> vasodilator. Further, the Paramedic should know that oxygen administration

> and NTG

> administration can alter the EKG findings in certain cases; therefore, it is

> reasonable and prudent to obtain a 12-lead prior to administering NTG if

> possible.

>

> There are always exceptions to every rule, and circumstances alter cases.

> Every case turns upon its own facts. The practitioner is stuck with the

> facts,

> no matter what they are. This is where assessment skills, critical

> thinking, and judgment come into play. An EMT is not expected to exercise

> the same

> level of assessment skills as a Paramedic, although he may be quite capable

> of

> thinking critically and using judgment up to his education and training

> level.

> The Paramedic is not expected to exercise all the same skills as a

> physician, although in some matters they may be equal.

>

> So, it may be reasonable and prudent for an EMT to assist the patient in

> taking her NTG so long as an adequate assessment, performed at the EMT's

> level of

> education, training, and experience, shows no contraindication. It might NOT

> be reasonable for the Paramedic to administer NTG to the same patient

> depending upon what the assessment findings are. Remember, if you have

> assessment

> toys, it's best to use them. Therefore, decline to use the EKG monitor at

> your peril. The jury will not understand why you didn't use the expensive

> toy

> you were provided if they are convinced you should have.

>

> The lawyer will ask a paramedic whether or not he did a 12-lead and started

> an IV prior to giving the NTG. Yes or no. That's all that need be asked.

>

> Then, if the patient crashed, the plaintiff's expert will testify that the

> paramedic should have done a 12-lead and started an IV prior to giving the

> NTG

> and explaining all the reasons why. The expert will explain that the 12-lead

> would have revealed the condition that contraindicated NTG, and that had an

> IV been started, the hypotension could have been corrected, or prevented by

> a

> bolus prior to NTG administration, et cetera.

>

> The average medic will be unable, generally, to defend this, since most will

> lack the sophistication of the expert witness, the ability to " teach the

> jury "

> and deal with the nuances. [Of course this does not apply to any member of

> this list, each of whom would certainly blow the plaintiff's expert out of

> the

> water and leave them in tears. LOL]

>

> So, when considering what to do, what not to do, and when to do it, ask

> yourself, is it reasonable and prudent for me as a (your level of

> practitioner) to

> do this? That's the question you will have to answer if things go South.

>

> Gene Gandy, JD, LP

>

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