Richard B the EMT

That sounds like proof of my position that the 9-1-1 systems are victim to their own success.

Telling the cooking staff that a child has specific allergies simply means, if they have individually cooked meals, they can be prepared in such manner that the allergy foodstuff won't be included in that child's meals. I have friends with children, and the children's allergies go from peanuts, to wheat, to milk. Some of these 4 year olds have "epi-pens" that they carry with them at almost all times. As for the birthdays, "My child cannot have any cake with peanuts, wheat, milk products, or chocolate in it, but he definitely should have a birthday cake!"

There seems to be an unspoken agreement with all of the EMS providers here in the USA: They are either dead at the scene, or dead at the hospital, as nobody dies in the ambulance during the trip to the hospital! Any commentary from outside of the US?

I wish I could say that there are no supervisors on power trips, but I hate lying. There are some good ones , too.

The War of 1812 was fought for, amongst other things, Brit ships stopping American Flag ships, stating that any crewman they saw was a Brit, and take him by force to serve on the Brit ship. They had actually stopped this before the shooting started. The Battle of New Orleans, perhaps the most famous battle of that war, due to no electronic communications, and depending on the fastest sail ships transporting mail in that period, actually was fought at least 2 weeks after the Peace Accords were signed, So... the battle was fought after the war was already over-they just didn't know it yet.

How about, with case by case consideration, a 14 to 16 year old as a dispatcher, and WITH AN AGENCY QUALIFIED Crew chief/EMT in direct supervision, 16 to 19 for ride along (usually meaning doing nothing without a "Mother/Father may I" from the Crew Chief. Probably end up being an equipment "Pack Mule")?

OK I put in the side step comment, and it is unwarranted. The NY State Police basically said, we're not making a decision, but will support you in whatever decision you make. Leastwise, that is my take on it.

I started working or volunteering in EMS when I was 19, in 1973. I didn't get a car until 1980, so I used to ride my bicycle the mile and a half from home to the station! If I responded by bicycle directly to the scene, it was only as unrequested backup to the assigned ambulance!

Just skimming the article, but does the reflective striping on my "Turnout/Bunker Gear" qualify, or will I have yet another item to carry with me? PS, I have a vest that I use in my off duty stopping at roadside scenes. My doing that has already been discussed numerous times on other strings (USE THE SEARCH FUNCTION!).

OK, folks, the New York State Police, in an unsigned response to my letter, has sent the following (side-stepping) statement: Anybody know which state, if any, "Dog" Chapman is "regulated" either in or by? We all know that it sure is none of the states of Mexico! If and when the New York State Department of Health responds, that will also be included.

Why not? While some of us use the term CHAOS (Chief Has Arrived On Scene) as a humorous term, there is somewhat of a need. In an MCI (Multiple Casualty Incident), which, per my training and standards, is any event that generates, or has potential for generating, 5 or more patients, or is one patient more than can actively be attended to by the crews from 2 ambulances (at 2 EMSers per ambulance), someone has to be the responsible party to request however more ambulances, and what levels (ALS or BLS) need respond, be the one with the information of what hospitals can take how many of specified category patients (so as not to simply transplant the MCI from the scene to any one particular hospital), or order up specialty units like HazTec, or the MIRV (Mass Incident Response Vehicle). First due supervisors usually are Lieutenants, followed by Captains, Chiefs, Division Chiefs, and Citywide level Chiefs (I am restricting my posit to FDNY EMS, and not including FDNY firefighting, or NYPD LEO resources). If an EMT or Paramedic is running Triage or Staging sectors, and the officer feels that person is handling the job well, they most times won't pull them off the post. Now, as for unified command posts, where we have the interaction between FDNY EMS, FDNY, NYPD, Transit Authority, Conrail, and CHEMTREC, in any combination of any of these agencies, or others I have not mentioned here, then, I believe it behooves all such agencies to have Hi ranking personnel at that unified command post, no matter which agency is considered the "Lead" agency for the incident, or type incident.

Someone else asked, I just took it to what I felt was the next logical step. I guess that makes at least 2 of us, and actually includes any and all who follow this string.

The following is addressed to the New York State DoH, and the NY State Police: To whom it may concern: A question came up on an EMS related web site/bulletin board, of which I am a member. We in the Emergency Medical Services System extend any and all courtesies possible to Law Enforcement Officers (LEOs), for both requesting them to ride or follow the ambulances if the crews feel threatened by a patient, or have them escort one of their prisoners to the hospitals aboard our ambulances, as well as other interactions between EMS and LEO. The question mentioned was, what about "Bail Enforcement Agents", perhaps more commonly known as "Bounty Hunters"? Due to patient confidentiality rules, and other policies, we are not supposed to allow anyone other than family, friends, or duly authorized LEOs, to accompany a patient. To the best of my knowledge, despite the Bail Enforcement Agents having firearms (and hopefully, the permits for same), some wearing uniforms, or at least so-called "Raid Vests", they are not sworn officers, either Police or Peace Officer status. If they (the Bail Enforcement Agents) have an individual "in custody", and said individual requires our skilled help, what are the policies that we in EMS are to follow concerning these "Agents"? Are they allowed to ride with their "prisoner"? Or, do we contact the local LEOs to accompany the patient? It is my intent to publish your response on the EMS web site, without editing anything out. Thank you in advance for any help your agency can give me, and the web site. Respectfully, Richard B (Address and real name edited out for publication on EMT City, for MY privacy.

Unless the individual is known by me to be a LEO (as in a "plainclothes" detective), is a uniformed LEO, or is vouched for as a LEO by a uniformed LEO, sorry, you ain't gettin' into my ambulance! Sorry, Mr Chapman. Actually, I'll ask the NYPD, the NY State Police, the NY State DoH, and post their responses.

Does the incident I mentioned, with me in my POV, even though it was outside my VAS office, and next to my ambulance, as it was my crew, or are the incidents to be related here cover only while IN the ambulance?

I lifted it directly from the file sent to me, and the rest of the New York State Volunteer Ambulance and Rescue Association's District 4, and put it in as shown. PM me, and I'll send the file to any requesting members of the city, but please mention EMT City in the subject line, or it goes into the etherial waste basket.

Just recalled another one, and I was driving. Traffic going slow on the Belt Parkway eastbound. We came over the bridge, and see a car accident a short way ahead, but it seemed everyone was out of the cars. This was in a section running through Gateway National Recreation Area, and a Federal Park Police car, driving on the grassy shoulder, passed us, slowly but at L&S. Cop happened to be a member of my VAS, but I was on a non-9-1-1 service provider. The "OMG" squad, AKA the "Rubbernecks", were out in full force, as everyone passing the scene was gawking at it, while slowing down. Perhaps I should cross reference this to the string on EMS Superstitions, but I remember commenting to my partner that some damn fool wasn't going to be looking at traffic, instead would be looking at the crash, and would not see another poor damn fool slowing down to look, and would hit the leading car. With that, BOOM! We got tail ended! In full view of my friend, the "Federalie". When he finished with the original incident, he wrote up the driver who had hit me, for "Inattention at the wheel". Does this one count? I was in my POV, with the battery jumper cables from my car to my VAS ambulance, in the right hand lane nearest to the parking lane. It possibly could be argued I was double parked, but my POV had all those rear facing emergency flasher lights that have some here calling me "Buff" or "wacker", which were activated, even though it was still bright daylight. Suddenly, the screech of wheels, and my POV was slammed from the rear by a car leaving the public parking lot. The driver jumped out of his car, ran up to my window, and started screaming at me for cutting him off. He went on for a few moments, until he realized he was now surrounded by my brother and sister VAS members, who he started berating. Then he started complaining to the NYPD "foot post" LEOs, who had walked over, telling them to ticket ME. He shut up, however, when he realized the entire VAS crew had witnessed the accident, as well as the 2 LEOs, and the 10 Fire Fighters from FDNY Engine 268 and Ladder 137, who had been talking with the LEOs. All surrounded him, and gave him the proper idea that he had hit MY vehicle IN THE REAR, which under NY State Law, made him responsible for hitting a clearly defined Parked vehicle. The fool was lucky in only one thing, that his insurance, while about to expire, had one more day to be in effect. I was extricated, and then transported by the municipal ambulance, as the VAS ambulance still would not start, and I left the hospital a few hours later with pain killers for back spasms.

In the strings on EMS week, having food set out for the crews has been mentioned. The usual complaint is, by the time the midnight to daylight crews get there, either all the food's been consumed, or has gone stale, and the "mid-nighters" usually end up cleaning up the food's wreckage left by the Dawn to dusk, and the dusk to witching hour crews.

Any word on Ms. Dubois' partner's condition, or their patient, if they were on a call? I also extend my condolences to her family, friends, co workers, and anyone who knew her.

I don't recall any other than one, while I was still in a non-9-1-1 service provider, we got sideswiped while enroute to the ER with CPR in progress. Very minor body damage to the type 2 and the other car. My partner got out, and told the other driver where we were going, and why we had to leave the scene of the accident. I don't recall if the patient was a "Quality of Life" save, but the patient was a "save" (circa 1975-1977).

FDNY EMS bills the 3rd party insurers of the patients first, as in Blue Cross, GEICO, Medicaid, Medicare, or other private and public health insurers, then goes after the difference, if any, from the patient or their family. If no insurance, the bill goes directly to the patient or their family. If they cannot pay, or fell off the radar, NYC taxes handle it. (We have some kind of allowances for paying on time) NYC usually does not do direct from the scene to hospital Medevacs. If the patient is flown anywhere using New York City equipment, specifically the helo, the transport is done with an NYPD helo, and an FDNY EMS EMT or Paramedic riding along. NYPD does NOT bill for medevac services provided, but I don't know if FDNY EMS charges for the ride along EMS member.

Itku, is the man applauding Orson Wells?

« STATE OF NEW YORK DEPARTMENT OF HEALTH 433 River Street, Suite 303 Troy, New York 12180-2299 Richard F. Daines. M.D. Wendy E. Sawnders Commissioner Chief of Staff August 1, 2008 Dear Colleague: The purpose of this letter is to clarify c,urrent New-York State (NYS) provisions for sharing of confidential information in cases of occupational potential exposure to H1V; to ask that you review and update applicable policies and procedures and to request your help in making sure that emergency responders know the steps to be taken in such situations. Although preventing exposures to blood and body fluids is the primary means of preventing occupationally acquired Human Immunodeficiency Virus (HIV) infection, appropriate post exposure management is an important element of workplace safety. Each emergency response agency is required 10 have plans in place for post exposure management. ill cases of significant exposure, seeking medical treatment immediately is crucial. NYS Department of Health (NYSDOH) guidelines recommend that post exposure prophylaxis (PEP) should be initiated as soon as possible, ideally within 2 hours and generally no later than 36 hours post-exposure. Emergenc>; responders should go to the nearest emergency room for evaluation of exposure. We are Vriting at this time due to changes to the federal law that previously governed. the manner in which response agencies could seek information. As background, the original Ryan Vhite law sections 2681·2690, passed in 1990 (public law 101-381, section 411) containing emergency response provisions for notification ofpossible exposure to infectious diseases, ,"vere not included in the 2006 Reauthorization. These provisions required emergency response employers (i.e., fire departments, police departments, emergency medical services} to have a "designated officer" to field calls from employees regarding possible exposures to communicable diseases and obtain the disease status of the patients in those exposures from the medical facility providing treatment to that patient. This language was included in subsequent reauthorizations ofthe Ryan Willte law until 2006, when public law I09~415 eliminated them. Despite these changes to the federal law, emergency response agencies can still access HIV test results on patients when there has been a bona fide risk exposure. KYS regulations now govern the manner in which disclosure of the HIV status of a patient may be made to emergency responders. Section 63.8(m)ofTitle10 oftheNewYorkCodes, RulesandRegulations (enclosed) provides for disclosure in such instances. Section 63,8(m) differs from the previous federal tawas [0110>"8: • (1) The federal law required disclosure to a "designated officer" ofthe emergency response employer. Under Part 63.8(m), sLlch disclosure may be made to the physicians or other medical providers ofthe emergency responders. (2) The federal law did not require knowledge of the HIV status of the emergency responder for disclosure of the patient's HIV status. NYS regulations for disclosure require that the emergency responder's status is HIV-negative. Ifthe emergency responder's mv status is unknO'IlTI, an HIV test must be offered and administered 1th consent ofthe emergency responder. Therefore, the following steps are now required when a significant ri1'k exposure occurs: L .-n incident report documenting the details ofthe exposure, including witnesses to th~ incident, ifany, is on record v,ith supenisory staff. 2. A request for disclosure ofthe patient's HIV status is made to the patient's physician or to the medical provider designated by the hospital or clinic to which the patient is brought. This request may be made by the exposed person (EMS provider) or by his or her physician as soon as . possible after the alleged exposure if a decision relating to the initiation or continuation of postexposure proph.ylactic treatment is being considered. 3. The medical provider ofthe EMS provider or the medical provider designated by the hospital or clinic must review, investigate and evaluate the incident and certify that: (a) the information is necessary for immediate decisions regarding initiation or continuation ofpost-exposure prophylactLc treatment for the EMS provider; and ( the EMS provider's status is either HIV negative or unknown and that ifthe patient's status is unknown, the EMS provider has consented to an HIV test; and © ifthe EMS provider'''l test result becomes knovm as positive prior to the receipt ofthe patient's HIV stanIS, no disclosure of the patient's H1V status v,ill be made to the EMS provider. 4. Documentation of the request is placed in the medical record ofthe EMS provider. 5. If the patient's physician or the medical provider designated by the hospital or clinic detennines that a risk oftransmission has occurred or is likely to have occurred in the reasonable exercise afms/her professional judgment, the patient's physician or medical provider designated by the hospital or clinic may release the HIV status ofthe patient, ifknovm. The patient's physician or medical provider in the hospital or clinic may consult v,ith the local director or commissioner ofpublic health to detennine whether a risk oftransmission exists, Ifconsultation occurs, both the medical provider ofthe hospital or clinic and the local director or commissioner ofpublic health must be in agreement ifthe Iffi' information is to be dlsclosed. in the disclosure process the name ofthe patient shall not be provided to the EMS provider. Redisclosure ofthe HIV status ofthe source is prohibited except when made in conformance with Public Health Law ,Article 21, Title III. In addition to the above, the NYSDOH recommends that, if the patient's HIV status is not known, consent of the patient be obtained for a rapid HIV test. Rapid test results are usually available within 30 minutes ortesting. Rules regarding confidentiality and consent for testing are identical to those for other HIV tests. A fonn, titled "Informed Consent to Perform a Coniidential HIV Test and Authorization for Release of HIV-related Information for Purposes of Providing PosI-exposure Care to a Health Care Worker Exposed to a Patient's Blood or Body Fluids" (DOH· 4054, Rev 8/05) is enclosed. This form is available at the NYSDOH web site at: http://m..-v.'.nyhealth.goviforms/doh-4054.pdf. The EMS providers' medical provider could request that the hospital try to secure a rapid HIV test of the patent. An informational slide s.et has been developed by the Department to aid emergency response agencies in implementing the above provisions. It is available on-line at: http://wHV.health.state.ny.us/nvsdohfems/bemsuodates.htm. At this time, your organization should review and update its policies and procedures to ensure that they are in compliance -lth section 63.8(m) and notify individual emergency responders ofthe procedures to be followed in cases ofpossible exposure. Specific questions should be directed as follm.'s: 1. Emergency medical response organizations should contact the NYSDOH Bureau of Emergenc)' J·...1edical Services at: (518) 402-0996, Ext. 2. 2. Police agencies should contact the NYS Police, Bureau ofMunicipal Police, at (518) 457-2667. 3. Fire Departments should contact the NYS Department of State. Office ofFire Prevention and Control at (518) 474-6746. NYSDOH AIDS Institute recommendations for PEP follo;ng occupational exposure are based on careful re'lew of available studies and constitute the considered opinion ofexpert HIV clinicians. They are available for review on the NYSDOH HrV Guidelines Website at -vwvli.hivguidelines.org. In addition, clinical assistance is available through the NYSDOH HIV Clinical Education Initiative's PEP, Te~iing & Diagnosis Center of Excellence (212~604~2980), This Center provides education and te-chnical ass.istance to providers regarding PEP. This Center operates the PEP Line (1-888-448-4911), a 24-hour provider consultation line for the management of PEP. Enclosed for your reference are copies of Part 63.8(m) and a letter from the Department to hospitals in NYS that notifies them ofthe status of the fed.crallaw and applicable NYS regulations. Your attention to this matter is appreciated. Sincerely, ;;u~Jvr1~1 Edward G. Vronski Director Bureau of Emergency Medical Services Enclosures (4) -Part 63.S(m) of Title 10 NYCRR -DOH·4054 . Letter sent to hospitals -Letter sent to health departments T;,I.l0 NYCRR: Part 63.8(m) as of April 2008 (m) Vhen the requirements of this section have been met, physicians and other diagnostic providers may disclose HIV-related information to physicians or other diagnostic prov.iders of persons whom the protected individual may have exposed to HIV under the circumstances noted below that present a risk of transmission ofHIV, except that disclosures related to exposure:; of emergency response employees governed by federal law shall continue to be governed by such law: (1) the incident must involve exposure to blood, semen, vaginal secretions, tissue or the follov.ing body fluids: cerebrospinal, amniotic, peritoneal, synovial, pericardia! and pleuraL and (2) a person has contact with the body substances, as noted in paragraph (1) above, of another to mucus membranes (e.g.. eyes, nose, mouth), ml1l-iiltact skin (e:g., open wound, skin Vyith a dermatitis condition, abraded areas) or to the vascular system. Examples of such contact may include ncc:dlesticks; puncture wound injuries and direct saturation or permeation of oonintact skin by potentially infectious substances. These circumstances shall not include those delineated in subdivision (d) of section 63.10; and (3) the exposure incident occurred to staff, employees or volunteers in the performance of emplo)'lnent or professional duties: (i) in a medical or dental oftlce; or (ii) in a facility regulated, authorized or supervised by the Department of Health, Office of'Nlental Health, Office of Mental Retardation and Developmental Disabilities, Office of Children and Family Services, Office ofAlcoholism and Substance Abuse Services, Department of Correctional Services; or (iii) involved an emergency response employee, paid or volunteer, including an emergency medical technician, a firefighter, a law enforcement officer (e.g., police, probation, parole oftleer) or local correctional officer or medical staff; and (4) an incident report documenting the details of the exposure, including v.itnesses to the incident, if any, is on record with supervisory staff; and (5)arequestfor disclosure ofHIV statusismade to the providerofthesourceortothe medical officer designated by the facility by the exposed person or by the provider ofthe exposed person as soon as possible after the alleged exposure if a decision relating to the initiation or continll3tion afpost-exposure prophylactic treatment is being considered; and (6) the medical provider of the exposed person or the mediC21 officer designated by the facility revit:ws, investigates and evaluates the incident and certifies that: . (i) the infomlation is necessary for immediate decisions regarding initiation or continuation of post-exposure prophylactic treannent for the exposed person; and (ii) the exposed person's status is either mv negative or unknovm. and that if the person's status is unknOin, the person has consented to an Hrv test; and (iii) ifsuch test result becomes knoVvu as positive prior to the receipt of the source's HIV status, no disclosure of the souTce's HI' status ill be made to the person; and (7) documentation of the request is placed in the medical record of me exposed person; and (8) if the provider of the source or the medical officer designated by the facility detennines that a risk of t:ransmission has occurred or is likely to have occurred in the reasonable exercise of hisfher professional judgment, the provider or medical officer may release the HIV status ofthe source, ifkno.V1l. The provider or medical officer may consult v,,;"'.h the municipal health commissioner or district health officer to determine whether a risk of transmission exists, If consultation occurs, both the provider and the local health officer must be in agreement if the HIV information is to be disclosed. In the disclosure process the name of the source shall not be provided to the exposed persall. Redisc10surc of the HIV status of the source is prohibited except 'vhen made in conformance '''lith Public Hc.alth Law Article 21, Title III. NEW YORK STATE DEPARTMENT OF HEALTH Informed Consent to Perform HIV Testing AIDS Institute and Authorization for Release of HIV-related Information for Purposes of Providing Post-exposure Care to a Health (are Worker Exposed to a Patient's Blood or Body Fluids, An employee has been exposed to your blood or 11 body fluid in a manner which may pose a risk fortrllnsmission of a blood-borne infection. Many individuals may not know whether they have a btoodborne infection because people can carry these viruses without having any symptoms. We therefore are asking for consent to test you for tile presence of human immunodeficiency virus (HNl, the virus that causes AIDS. You willalso be tested for hepatitis Bvirus (HBVl and hepatitis (virus jHCV). Under New York State law, HIV testing is lIoluntary and requires COnsent in writing lconsent can be withdrawn for testing at any time.] There afe a number of tests that can be done to show if you are infected with HIV. Your provider or counselor can provide specific information on these tests. Anonymous testing is available at selected sites. These tests involve collecting and testing blood, urine or oral fluid. Additional testing also wilt tell whether you are carrying HBV or HCV. HlV Testing is lrnportant for Your Health If your test result is negative. you can [earn how to protect yourself from being infected in the future If your test result is positive: You can take steps to prevent passing the virus to others ~ You can receive treatment for HIV and learn about other ways to stay healthy. As part of treatment, additional tests will be done to determine the best treatment for you. These tests may include viral load and viral resirtilnce tests. An infected mother (an pass HIVto her child during pregnancy or birth ortnrough bre1lstfeeding. • If you are pregnant and have HIV, treatment is available for your own health and to prevent passing HIV 10 your baby. If you have HIV ,md do not get treatment, the chance of passing HIV to your baby is one in four. If you get treatment, your chance of passing HIVto your baby is mllch tower, If You Test Positive: State law protects the mnfidentiality of your test results and also protedsyou from discrimination based on your HIV status. In almost all cases, you will be asked to give written approva,l before your HIV lest can be shared. Your HIV information can be released to health providers caring for your oryour exposed child; to hea1h officials when required by law; to insurers to permit payment; to persons involved in foster care or adoption; to officiat correctionaL probation and parole staff: to emergency or health care staff who are accidentally exposed to your blood; or by special court order. The names of persons with HIV are reported to the State Health Department for tracking the epidemic <lndfor planning services. The HIV Confidentiality Hotline at 1-800·962-5065 can answer your .questions and help with c.onlldentiatity problems. The New York State Division of Human Rights at 1·800·523·2437 can help if you think you've been discriminated against based on your HIV status. If you are positive, your counselor/doctor will talk with you about notifying your sex or needle-sharing partners of fXl~sible exposure to HIV. • Your partners need to know that they may have been exposed to HIV so they can be tested and get treated if they have HIV. If your health care provider knows the name of yourspouse Of other partner, he or she must report the name to the health department unless itwould result in harm to you. • Health department counselors can help notify your partnens) without ever telling them your name. • To ensure your safety, your counselor or doctor will ask you questions about the risk of domestic. violence for each partner to be notified. If there is any risk. the Health Department willno1 notify partners right away arld wilt assist you in getting help. DOH-4054 (Rev. 8/051. compliant with 45 tF.R. of 164.5D8((4)1iii) [HlPAA] You are atso being asked to authorize the release of confidential HIV-related information related to this consent for testing to the health professional, named below, who is treating the healtn care worker that has been exposed to VOlJr blood or body fluid. This is necessary to provide appropriate care ~nd to counsel the worker about his or her risk of becoming infected and possibly infecting other$. Under New York State law Hrv-reLated information can only be given to people vou aLLow to have it by signing a written release, except in the instances outlined above. These individuals are prohibited by law from re-disclosing testing results in a way that could reveal your identity. Name and address of facility/provider disdosing HN-reLated information: Name and address of facilityjproviderto be given HIV-related information: DescrilH! information 10 be released: t1IVTest Results Time period during which release of information is authorized From: _ Too _ You may revoke this release, but disclosures caortot be revoked, once made, Additional exceptions to the right to revoke this release. ifany: _ Describe consequences, if any, of failing to tonsel1t to disdosure upon treatment, payment, enrollment or eligibility for benefits. (Note: Federal privacy regulation may restrici some consequences): _ Iunderstandthat Iambeingaskedtosubmitaspecimenfor HIVtestingfor oc.cupationalexposure,Iagreetotestingforthe determination of HIV infection. If] am found to have HIV,1 agree to additional testing that may occur on the sample I provide today to determine the best treatment for me and to help guide HIV prevention programs.lalso agree to future tests to guide my treatment I understand that I can withdraw my consent for future tests at any time. Jalso authorize release of this information to the health care professional, named above, who is treating the health care worker that has been exposed to my blood or body fluid. Signature: (Test subject or legally authorized representative) Printed Name: _ Date: Patient 10#: DOB: Address: If legal representative, indica'te relationship to subject: DOH-4054 (Rev. 81051, wmp!;~nt with 45 c.F.R, of 16450S(bl(4-l(fiij [HIPAAj STATE OF NEW YORK DEPARTMEIlT OF HEALTH 433 RWer Street. SUite 303 Troy, New York 12160·2299 Richard E Daines, M.D. Comrr[iSSiOOO( Wel1c'y E Saunders ClJJef of Staff August 1, 2008 DPACS, 08 -06 Dear Chief Executive Officer: The purpose of this letter is to clarify New York State ~"'lS) provIsions for sharing ofconfidential information in cases ofpotcntial occupational exposure of emergency responders to HIV, to ask that you review and update appllcable policies and procedures and to request your llelp in making sure that hospital staffknow the steps to be taken in such situations. . The original Ryan ;bite law, enacted in 1990, contained provisions by which emergency response agencies (I.e., fire departments, police departments, emergency medical senices) were required to have a "designated officer" to field calls from employees regarding possible exposures to communicable diseases and obtain the disease status of the patients in those exposures from the medical facility providing tream1ent to that patient. This language was included in subsequent reauthorizations of the Ryan White law until 2006, when Public Law 109-415 eliminated them. Despite these changes to the federal law, emergency responders can access EIV test results on patients when there has been a bona fide risk exposure. NYS regulations now govern the manner in which disclosure ofthe HIV status ofa patient may be made to emergency responders. Section 63.S(rn) ofTitle 10 of the New York Codes. Rules and Regulations provides for disclosure in such instances. Section 63.8(m) differs from the previous federalla" as follows: (1) The federat law required disclosure to a "desigriated officer" oftne emergency response employer. Under Part 63.8(m), such disclosuc(': may be made to the physicians or other medical providers ofthe emergency responders, (2) The federal lawdidnotrequireknowledgeoftheHIVstatusofthe emergency responder for disclosure of the patient's HIV status. NYS regulations for disclosure require that the emergency responder's status 15 HIV·negative. If the emergency responder's HIV status is unknown, an mv test must be offered and administered with consent ofthe emergency responder. Therefore, the fcllowing steps are nov.' required when a significant risk exposure occurs: 1. An incident report dOc:umC'llting the details of the exposure, including witnesses to the incident, ifany, is on record ,vith supervisory s.taff at the emergency response agency. 2. A request for disclosure ofthe patient's HlV status is made to the patient's physician or to the medical provider designated by the hospital or clintc to which the patient is brought. This request may be made by the exposed person (emergency responder) or by his 0]' her physician as soon as possible after the alleged exposure ifa decision relating to the initiation or continuation afpasl-exposure prophylactic treatment is being considered. 3. The medical provider ofthe emergency responder or the medical provider dcsignat~d by the hospital or clinic must review, investigate and evaluate the incidem and certify that: (u) the information is necessary for immediate decisions regarding initiation or contilluation ofpm:t-exposure prophylactic treatment for the emergency responder; and ( the emergency responder's status is either HIV negative or unknown and that if the patient's status is unknown, the emergency responder has consented to an HN test; and (c.) ifthe emergency responder's test result becomes known as positive prior to the receipt ofthe patient's HIV status, no disclosure of the patient's HIV status will be nude to the emergency responder, 4. Documentation ofthe request is placed in the medical record Qftbe emergency responder. 5, Ifthe patient's physician or the medical provider designated by the hospit..1.1 or ..::linic determines that a risk oftransmission bas occurred or is likely to have occurred in the reasonable exercise ofhis/her professional judgment, the patient's physician or medical provider designated by the hospital or clinic may release the HIV status of me patient, if known. The Patient's physician or medical provider in the hospital or clinic may consult with the local director or commissioner ofpublic health to deter:mh1e whether a risk of transmission exists. Ifconsultation occurs, both the medical provider of the hospital or clinic and the local director or commissioner ofpublic health must be in agreement ifthe HIV iniormation is to be disclosed, In the disclosure process the name of tho patient shall notbeprovidedtotheemergencyresponder. Redisclosure oftheHIVstatusofthesource is prohibited except when made in confonnance with Public Health Law Article 21, Title IlL Although preventing exposures to blood and body fluids is the primary means of preventing occupationally acquired HIV infection, each emergency response agency is required to have plans in place for post exposure management. In cases ofsignificant exposure, seeking medical treatment immediately is crucial. NYS Department ofHealth (N"YSDOH) guidelines recommend that post exposure prophylaxsis (PEP) should be initiated as soon as possible, ideally within two (2) hours and generally no later than 36 hours post-exposure. Emergency responders usually rely on hospital emergency rooms for evaluation ofexposure and emergency re~ponse agencies have established relationships 'I,1,ith hospitals for purposes of accessing confidential infomlation about the HIV infection status ofpatients. In addition to the above, the NYSDOH recommends that if the patient's HIV status is not known, consent of the patient be obtained for a rapid HIV test. Rapid test results arc usually available within 30 minutes oftesting. Rules regarding confidentiality and consent for testing are identical to those for other HIV tests. A fom), titled "Informed Consent to Petform a Confidential HIV Test and Authorization for Release of illV-relatetllnfonnation [or Purpose~ of Providing Post-exposure Care to a Health Care Worker Exposed to a Patient's Blood or Body Fluids" (DOH· 4054, Rev 8/05) is attached. This fonn is available at the NYSDOH web site at: http:/.rv."'v.n}11 ea.1tll .goviforms/doh-4054,pdf. At this time. your hospital sboultl review and update its policies and procedures to ensure that they are in compliance with section 6J.8(m) and notify individual staff ofihe proc.edures to be followed in cases ofpossible ex.posure. :r-.:Y"SDOH AIDS Institute recommendations for PEP following occupational exposure arc bascd on careful review ofavailable studies and constitute the considered opinion of expert HIV clinicians. They are available for review on the NYSDOH HIV Guidelines V....ehsite at V'.'.hiv!.!uidelines.org. Ifyou need clinical assistance please contact the NYSDOH HIV Clinical Education Initiative's PEP, Testing & Diagnosis Center ofExcellence (212-6042980). Tbis Center provides education and technical assistance to providers regarding post-exposure prophylaxis. This Center operates the PEP Line (1-888-448-4911), a 24hour provider consultation line for the management of post-exposure propbylaxis. Artached for your reference is a copy ofPart 63.8(m) and letters from the Department to emergency response agencies and local health departments in NYS notifying them of the status ofthe federal law and applicable NYS regulations. Your attcIltion to this matter is appreciated. Sincerely, 1viartin 1. Conroy Director, Division ofPrimary & Acute Care Services Attachments: -Part 63.8(m) ofTitle 10 NYCRR -"Informed Consent to PerfonTI a Confidential HJV Test and Authorization for Release ofHIV-related Information for Purposes ofProviding Post-exposure Care to a Health Care Vorker Exposed to a Patient's Blood or Body Fluids" (DOH-4054, Rev 8/05) • Letter to emergency response agencies -Letter to Local Health Department& STATE OF NEW YORK DEPARTMENT OF HEALTH Coming Tower The Governor Neison A. Rockefeller Empire Stele Plaza. Albany, New York 12237 Richard F. Daines, M.D. Commissioner Wendy E. Sau,.,ders ChiefofStaff August 1, 2008 Dear Commissioner or Director of Public Health: The purpose of this leiter is to inform you ofa change in federal1aw that has implications for the local health departments in New York State (NYS) regarding emergency responders' access to confidential health 1nformation in cases ofpotential occupational exposure to HIV. Since 1989, ~'~{S regulationshaveprovideda processfor disclos-ureofprotectedinformationthatincludeda defined role for local health departments to become involved in certain situations, as needed. SpecifiCally, consultation with local health departments regarding risk oftransmission and disclosure is provided for. Until recentlYt the NYS regulations wl're superseded in certain instances by fed~raJ law. As background, the original Ryan Vl-l1ite law, enacted ill 1990. contained provisions by which emergency response agencies (i.e" fire departments, police departments, emergency medical services) were to have a "designated officer" to field calls from employees regarding possible exposures to communicable diseases and obtain the disease status of the patients in those exposures from the medical facility providing treatment to that patient. This language was included in subsequent reauthorizations of the Ryan White law umi12006, v,.-hen Public Law 109~415 eliminated them. Despite these changes to the fe<lerallaw, emergency response agencies ill NYS can still access HIV test results on patients when there has been a bona fide risk exposure. NYS regulations now govern the manner in which disclosure ofthe HIV status of a patient may be made to emergency responders. Section63.8(m) ofTitle10oftheNewYorkCodes,RulesandRegulations (attached) provides for disclosure in such instances. Section 63.8(m) differs from the previous federal Jaw as follows: (l) The federal law required disclosure to a "designated officer" of the emergency response employer. Under Pa11-63.8(m), such disclosure may be made to the physicians or other medical pl'Ovid-2rs ofthe emergency responders. (2) The federal law did not require knowledge of the HIV status of the ~lUergency responder for disclosure of the patient's HfV Status. NYS regulations for disclosure require that the emergency responder's status is HIV-negative. If the emergency responder's HIV status is unknO',l1, an HIV test must be offered and administered with consent ofthe emergency responder. The following steps are new required when a significant risk exposure occurs. The involvement oflocal health departments as a resource for consilltation in Ihis process is underlined: 1. An incident report documenting the details of the exposure, including witnesses to th0 incident, if any, is on record with supervisory staff. 2. A request for disclosure oftlle patient's HIV status is made to the patient's physician or to the medical provider designated by the hospital or clinic to which the patient is brought. This request may be made by the exposed person (em~rgency responder) or by his or her physician as soon as possible after the alleged exposure if a decision relating to the initiation or continuation ofpost-exposure prophylactic treatment is being considered. 3. The medical provider ofthe emergency Jesponder or the medical provider designated by the hospital or clinic rmlst review, investigate and evaluate the incident and certify that: (a) the information is necessary ior immediate decisions regarding initiation or continuation cfpost-exposure prophylactic treatment for the emergency responder; and ( the emergency responder's status is either HIV negative or unknown and that ifthe person's slatu5 is unknown, the emergency responder has consented to an HrV test; and © if the emergency responder's test result becomes known as positive prior to the receipt of the patient's HIV status, no disclosure {lfthe patient's HIV status will be made to the emergency responder. 4. Documentation ofthe request is placed in the medical record of the emergency responder, 5. lfthe patient's physician or the medical provider designated by the hospital or clinic determines that a risk of tmnsmission has occurred or is likely to have occurred in the reasonable exercise ofhislher professional judgment, the patient's physician or medical provider designated by the hospital or clinic may release the HIV status ofthe patient. ifknown. The patient's physician or medical provider in thehosmital or clinic may consult with the local director or commissionerofpublichealthtodeterminewhetherarisk oftransmissionexists. Ifconsultation cceun, both the medical orovi.der oithe hospital or clinic and the local director or commissioner ofpublicheallh must beinagreementifthe mv info!J11a1ion is to bedisc!osed. In the disclosure process the name ofihe patient shall not be provided to the EMS provider. Redisclosure of the mv status of the source is prohibited except when made in confonnan<:e with Public Health Law irticle 21, iitle m. Although preventing exposures 10 blood and body fluids is the primary means ofpreventing occupationally acquired HIV infection, appropriate post exposure management is an important element ofworkplace safety. Each emergency re:sponse agency is required to have plans in place for post exposure management. Emergency response agencies in NYS are being notified about the change in federal law. They are asked to update their policies and procedures and to make sure that personnel know of tile steps to be taken in situanons involving potential exposures to HIV, Hospitals in NYS are also being notified, with a similar request to update their policies and procedures, At this cime, we ask that you review and update your Depaltmcnt's policies and procedures to ensure that they are in compliance with section 63.8(m) and that you notify any appropriate staff of the correct proce<lures to be followed when contacted by a patient's physician Of medical provider in the hospital or clinic. In cases of significant expostlJ'e, seeking medical treatment immediately is crucial. NYS Department of Health (NYSDOH) guidelines recommend that post exposure prophylaxis (PEP) should be initiated as soon as possible. ideally within two (2) hours and generally no later than 36 hours post·exposure. N"'YSDOH AIDS Institute recommendations for PEP following occupational exposure are based on careful review of available studies and constitute the considered opinion of expert HIV clinicians, They are available for review on the NYSDOH HIV Guidelines Website at wW'N.hivguideliues,org. Ifyou need dinical assistance please contact the NYSDOH HIV Clinical Education Initiative's PEP, Testing & Diagnosis Center of Excellence (212-604-2980). This Center provides education and technical assistance to providers regarding PEP, This Cl;:oter operates the PEP Line (1~888-448-491 J), a 24-hour provider consultation line for the management of PEP. Attached for your reference is a copy ofPart 63.8(m) and letters from the Department to emergencyresponseagencies andhospitals inNYSnotifying themofthe statusofthefederal law and applicable NYS regulations, Thank you for your attention to this maUer. Sincerely, G~kh~ Deputy Commissioner Office ofPubHc Health Attachments; Part 63.8(m) ofTit!e 10 NYCRR Letter to emergency response agencies Letter to hospitals

In that second photograph? http&#58;//i43.photobucket.com/albums/e392/n0ssb/S6300321.jpg The guy in the plaid shorts is either carrying some kind of weapon in his pocket, or is very happy to see that girl in the blue dress, standing in front of him!

I got vague memories of a commercial supporting the UN, where the idea posited was that "Wars should be fought by the old men, not the young." It showed two 75 plus year old men in the grey pinstripes of the Diplomatic Corps, with their "seconds" standing behind them, engaging in a bare knuckles boxing match, and appearing to be really wailing on each other.