http://statter911.com/2010/03/11/dc-police-conducting-review-of-par...

 

I read this and was, quite frankly disturbed at the precedent that would be set if there are criminal charges filed against the Paramedic involved.  Not that I don't disagree that they were way out of line and probably should not be in EMS.  What are your thoughts on this?

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This is always a difficult one, only 1 person can attempt to explain the decision making at that is the Paramedic in the room at that time.

It would be dealt very differently here, this would fall under a Fitness to Practice issue filed with the Health Professions Council and depending on the evidence available appropriate sanctions would be taken against the Paramedic. Being Struck Off being the most likely one if failures in patient care like those suggested in the media reports are true. Police would not be involved certainly not in the initial investigations.

We had a case here, where a crew attended a patient who had arrested whilst on the phone to dispatchers, the line was still open, and negative comments about the patient and their living conditions were recorded on the 999 call. The dispatch manager passed the incident directly to the police before any internal disciplinary proceedings. This is very unusual and in inner circles here, it sounded like the service was looking for an excuse to get rid of the medics in question and used the incident as the reason to do so. The crew was charged with "neglecting duties of public office and a position of trust"

Although i get the distinct feeling from the articles about the child case, that there appears to be major IT issues with the services EPRF system. By the service refusing to comment on how many forms are missing because of system failures or because of medics not doing them. More worryingly with small stations, the signed release and paper prf could have been made to disappear (but thats just my cynical side talking)

In terms of the clinical aspects of the case, we have a policy where all patients 2 and under are transported without question for evaluation by paed specialist doctors. This is regardless of how minor the chief complaint or whether it be more appropriate for primary care to deal with. This is based on our National Management Protocol for feverish illnesses in children http://guidance.nice.org.uk/CG47/Guidance/pdf/English

If parents refuse it becomes a child protection/safeguarding children issue, (physical abuse) "denying child access to medical treatments"

Without knowing whether this child was pyrexic or had any red flags prompting admission it is a guessing game. It seems though that laziness of transporting in poor weather conditions played a factor.

The point of discussion comes;
Did the medic fail to perform an adequate assessment?
Did the medic fail to provide treatments in line with assessment findings?
Did the medic fail to recognise that the patient's health needs were beyond their scope of training and fail to refer the patient to the appropriate health care professional?
Did the medic fail to provide the patient/relatives with enough information to arrive at an informed decision regarding the presenting healthcare needs?
Did the medic fail to keep records of the consultation?

If the answer is yes, then negligence becomes an considering factor of play. If it is a training/coaching issue, performance issue then fair enough identify areas of concern and act upon them whilst protecting the public. It becomes criminal when the root cause of the negligence is laziness on behalf of the medic.
There is some line where gross negligence crosses the line and could become "criminally negligent homicide." I don't think it's been worked out in any case involving EMS.

There have been several fire officers prosecuted in the US when reported negligence in managing fire operations or training has resulted in death. Some were convicted and sent to jail.

I read recently that several UK fire officers were questioned (after being advised of their rights, much like the US Miranda warning) by police, about an incident where death of firefighters occurred.
This is true, the fire officers were and I think still are facing charges of corporate manslaughter.

The corporate manslaughter act was passed after a public outcry following a train crash costing over 150 lives. The driver ran through a red light signal. But the train company failed to install industry standard safety features such as automatic application of brakes when a red signal is breached. The chief exec of the company got 12 years in prison I recall.

In the fire officers case, the service concerned were on special measures over their incident command and control structure and decision making. Officers were giving orders to enter buildings before being on scene. They were warned to sort it out. They didn't and more lives were lost as a result

Skip Kirkwood said:
There is some line where gross negligence crosses the line and could become "criminally negligent homicide." I don't think it's been worked out in any case involving EMS. There have been several fire officers prosecuted in the US when reported negligence in managing fire operations or training has resulted in death. Some were convicted and sent to jail.

I read recently that several UK fire officers were questioned (after being advised of their rights, much like the US Miranda warning) by police, about an incident where death of firefighters occurred.
There is some line where gross negligence crosses the line and could become "criminally negligent homicide." I don't think it's been worked out in any case involving EMS.

In s case such as this normally the crew would face internal discipline and sanctions from the medical director. If the case also includes "gross negligence" they could also face sanctions at the state level up to revocation of their license. This is the first time I have heard of possible criminal charges due to negligence.

Setting aside the details of this case (which I don't know), at what point does negligence on the part of an EMT and/or Paramedic become criminal? We all know that we can face civil lawsuits due to negligence, but where is the line? Does the patient have to die as a result of their actions or inactions? Or does the patient just have to have a lifelong loss of quality of life? I'm not sure where I stand on this yet.
I would think that there's a difference between civil liability for an (allegedly) negligent act like failing to transport a patient (wrongful death) and homicide. The EMS crew didn't kill the patient in the D.C. case, the disease process did. The same goes for the Pittsburgh blizzard case.

A couple of examples on the fire side...

In the Lairdsville, NY training LODD, the training chief was convicted of criminally negligent homicide actions that led to another firefighter's death at a live training fire.

In the case of the Thirtymile fire in Washington, the crew boss was convicted of lying to investigators, but the manslaughter charges were dropped.

In the fire cases, the problems were actions of commission. The DC and Pittsburgh EMS cases in the current news are actions of omission. Does that make a difference in either criminal or civil law? I'd think that a failure to take an action that may or may not have prevented a death are held to a lesser standard than actions that cause a death, or in the WA case, where the conviction was due to lying to investigators in a case that would probably have never resulted in a conviction on the more serious charges, and in fact did not result in such a conviction.

In regard to Dave M's comment, the legal system will trump the medical director's internal review every time, unless there is a state law that protects the EMS personnel from charges prior to the completion of a medical review.
Ben Waller said:
The DC and Pittsburgh EMS cases in the current news are actions of omission. Does that make a difference in either criminal or civil law? I'd think that a failure to take an action that may or may not have prevented a death are held to a lesser standard than actions that cause a death, or in the WA case, where the conviction was due to lying to investigators in a case that would probably have never resulted in a conviction on the more serious charges, and in fact did not result in such a conviction.

Hmm... I wonder what would happen to EMS if EMS got a Warren v DC style court decision that essentially says that there is no civil or criminal liability for failure to provide any meaningful response or transport.
Negligent homicide is a criminal charge brought against people who, through criminal negligence, allow others to die. This definition at least suggests that an act of omission would be sufficient. However, each state's criminal code is free to include its own definition, and then the courts "refine" that, so state-by-state legal research is required to get a specific answer for a specific case.

Negligent Homicide is a lesser included offense to first and second degree murder, in the sense that someone guilty of this offense can expect a more lenient sentence, often with imprisonment time comparable to manslaughter. U.S. states all define negligent homicide by statute. In some, the offense includes the killing of another while driving under the influence of drugs or alcohol. Examples of such cases include the crash of Aeroperu Flight 603 near Lima, Peru. The engineer who put the tape while cleaning the ill-fated Boeing 757 was convicted of negligent homicide after he forgot to take the masking tape (which was normally unused while cleaning airplanes) off.

"Criminal negligence" is one of the three general classes of mens rea (Latin for "guilty mind") element required to constitute a conventional as opposed to strict liability offense. It is defined as careless, inattentive, neglectful, willfully blind, or in the case of gross negligence what would have been reckless in any other defendant.

There seems to be a continuum that on one end is "intentional" and at the othe end "accidental", with a transition from criminal to civil happening somewhere in the vicinity of "gross negligence" and up.

Could be very interesting....
at what point does negligence on the part of an EMT and/or Paramedic become criminal? We all know that we can face civil lawsuits due to negligence, but where is the line? Does the patient have to die as a result of their actions or inactions? Or does the patient just have to have a lifelong loss of quality of life? I'm not sure where I stand on this yet.

I wonder whether it becomes criminal when the EMT/Paramedic deliberately ignores their training and protocols to suit their own needs at the time.

There's just been a paramedic struck off here recently for among other things, failing to transfer the patient from the back of the ambulance to the hospital ward on a cardiac monitor. The patient was post thrombolysis! The paramedic argued that the the 200 yard journey of 2 -3 minutes was insignificant and the delay of moving the monitor to a safe place on the stretcher mount would take close to 5 minutes. It was better that the patient was transferred to the ward than spend and extra few minutes in the ambulance. An opinion that the fitness to practice board disagreed with, citing that the patient was high risk for cardiac arrest and transferring with the defibrillator was in the patients best interests over reaching the ward promptly.

Was it a deliberate act on behalf of the paramedic?
Medic-initiated patient refusals are the 800 lb. gorilla in the EMS room, and are typically performed by only a handful of medics within each service. When questioned, almost everyone "knows" who leads the pack in obtaining refusals within each service. Some actually pride themselves on performing the fewest transports.

All EMS administrators should maintain statistics on patient refusals for each medic using comparable operational metrics (excluding MVA's and "no patient contact".) By doing so, the culprets quickly surface. I've seen a refusal rate as high as 38% of all patient contacts, compared to <5% for other medics with the same 911 assignments in the same district over a one-year period.

People call EMS with the expectation of being transported to a hospital, not to be evaluated and qualified for transport by an individual who sees himself as an itinerant medical practitioner, who happens to arrive in an ambulance, and who possesses neither the clinical knowledge, nor diagnostic and treatment capabilities that can be obtained at a hospital. Until this expectation changes, it's intuitive that these types of events will continue - if not escalate.
This is way of base.

Our service as a whole has a 47% non transfer rate. However we coin it as 47% of patients access an alternative care pathway. it is patients where transfer to the emergency department is not warranted and the patient accesses other healthcare providers. So that's close to half of the calls we receive are NOT taken to hospital.

We have pathways in place such as the Rapid Intervention Team which is designed for patients who have an exacerbation of a chronic medical problem. The team involves Primary Care Physicians, Specialist Nurses, Occupational Therapists, Social Workers and the manage the patient through the event in their own home and avoid hospital admission. Up to the point where patients receive IV antibiotics in their own home for relevant conditions.

I don't think anyone can elevate their ego by initiating a discharge on scene. I think it is pride that the patient is being referred to the best course of action for them. The question about not having the skills really boils down to the age old debate of EMS education that will go round and round for ever. BUT even our EMT's with 6-8 weeks medical training are initiating discharges with the right clinical support.

I can't upload the protocol at the moment but we have a traffic light system for various presenting complaints. So for example back pain. Red category - transfer to the emergency department, would include history of trauma with central lumbar pain. Inability to urinate, age of patient ect.... The yellow category are history features where a referral to an advanced practitioner is needed before discharge decision is needed. So this could be an advanced paramedic on scene or in most cases EMT's can access our nurse triage desk in the control centre for further advice. The green category of symptoms and history is where it is appropriate for the EMT to refer to an alternative pathway without assistance. So tell the patient to go and see their own doctor in the morning.

Key exceptions, as I mentioned before include patients aged 2 and under, patients with dementia ect where a reliable history and physical exam can be obtained...

My experience tends to suggest that people make contact with EMS because they have an emergency situation where they need immediate medical attention in the form of Paramedics. Very few people immediately want to go to hospital, it is far from that most patients particularly the elderly need great convincing to go even in the most life threatening of situations.

Problems arise when medics disregard the safe discharge practices and advice. It'll be all right have a good evening and close the door. No call us back if XY or Z happens, No make sure you keep an eye of the childs temperature give paracetamol at regular times, No you can call the 24 hour Nurse Hotline NHS Direct if you have concerns. Just everything appears okay see you later

Our national guidance committee is currently working on a "Leaving patients at home" clinical guideline. One thing that I liked, i think it was the North Carolina state protocols with the discharge form that highlights the key things that the patient needs to do, or say to their doctor. Currently we just have one A3 patient report form that serves all purposes and the safe discharge information isn't always easily available to the patient when they need it.

When the medic has performed a thorough clinical assessment, has used appropriate decision making skills to arrive at a differential diagnosis, has provided any on scene treatments (diabetic and glucagon IM, asthma and nebuliser) reassessed as a result of those interventions and confirmed differential diagnosis, provided the patient with enough information to make an informed decision (offering the community options on equal weighting to transport to hospital, if community option is taken the medic provides appropriate safety netting, when to call us back, what to keep an eye on and so forth. if this all this is provided to a satifactory standard then I feel EMS initiated discharge is appropriate.

When we start talking about criminal charges and negligence, we almost always find that corners have cut in the above process...if it is deliberate corner cutting then its criminal in my book!



Bob Kellow said:
Medic-initiated patient refusals are the 800 lb. gorilla in the EMS room, and are typically performed by only a handful of medics within each service. When questioned, almost everyone "knows" who leads the pack in obtaining refusals within each service. Some actually pride themselves on performing the fewest transports.

All EMS administrators should maintain statistics on patient refusals for each medic using comparable operational metrics (excluding MVA's and "no patient contact".) By doing so, the culprets quickly surface. I've seen a refusal rate as high as 38% of all patient contacts, compared to <5% for other medics with the same 911 assignments in the same district over a one-year period.

People call EMS with the expectation of being transported to a hospital, not to be evaluated and qualified for transport by an individual who sees himself as an itinerant medical practitioner, who happens to arrive in an ambulance, and who possesses neither the clinical knowledge, nor diagnostic and treatment capabilities that can be obtained at a hospital. Until this expectation changes, it's intuitive that these types of events will continue - if not escalate.
http://www.timesonline.co.uk/tol/news/uk/crime/article7051245.ece

The Paramedic involved in this incident just sentenced for 12 months. Not for clinical aspects of the case, but lying on official Coroner's Recognition of Death Forms.

Seems a jury will accept negligence as criminal?

Neil White said:


We had a case here, where a crew attended a patient who had arrested whilst on the phone to dispatchers, the line was still open, and negative comments about the patient and their living conditions were recorded on the 999 call. The dispatch manager passed the incident directly to the police before any internal disciplinary proceedings. This is very unusual and in inner circles here, it sounded like the service was looking for an excuse to get rid of the medics in question and used the incident as the reason to do so. The crew was charged with "neglecting duties of public office and a position of trust"

In that case, wouldn't the prosecution have to show that the death was completely avoidable with EMS transport/intervention, and wouldn't that be a pretty difficult proposition?

Skip Kirkwood said:
Negligent homicide is a criminal charge brought against people who, through criminal negligence, allow others to die. This definition at least suggests that an act of omission would be sufficient. However, each state's criminal code is free to include its own definition, and then the courts "refine" that, so state-by-state legal research is required to get a specific answer for a specific case.

Negligent Homicide is a lesser included offense to first and second degree murder, in the sense that someone guilty of this offense can expect a more lenient sentence, often with imprisonment time comparable to manslaughter. U.S. states all define negligent homicide by statute. In some, the offense includes the killing of another while driving under the influence of drugs or alcohol. Examples of such cases include the crash of Aeroperu Flight 603 near Lima, Peru. The engineer who put the tape while cleaning the ill-fated Boeing 757 was convicted of negligent homicide after he forgot to take the masking tape (which was normally unused while cleaning airplanes) off.

"Criminal negligence" is one of the three general classes of mens rea (Latin for "guilty mind") element required to constitute a conventional as opposed to strict liability offense. It is defined as careless, inattentive, neglectful, willfully blind, or in the case of gross negligence what would have been reckless in any other defendant.

There seems to be a continuum that on one end is "intentional" and at the othe end "accidental", with a transition from criminal to civil happening somewhere in the vicinity of "gross negligence" and up.

Could be very interesting....

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