Paramedic quit shortly after teen player's death

[Mateo_1387]

Orange County Protocols

I 'hear' this system can refuse transport and refer patients to appropriate medical facilities. I could not find within their protocols that they could refuse transport. I posted the link though if anyone wants to take a look.

[emsboy_2000]

First of all, from a legal liability standpoint, you have to determine what the law considers a minor to be. Not all states share the same medical definition of what constitutes a minor. In California, for example, (where I’m from) it is illegal to release anyone under the age of eighteen with a medical complaint or condition. When the parents can’t be reached, it becomes the responsibility of the EMS personnel, and even law enforcement—if need be, to ensure the patient’s medical well-being. This unfortunate situation has to be analyzed in the context of the state if occurred in.

Secondly, from a professional medical standpoint, if the patient was experiencing full body cramps or spasms, wouldn’t that lead one to think that perhaps this kid might be suffering from severe dehydration? And, perhaps…need an ER visit! I’m not sure that advising a patient—in that condition—to continue hydrating with water and Gatorade is the best advice. Most patients with full body spasms due to dehydration are beyond the point of what water or Gatorade can resolve. By most medical texts I’ve come across, spasms or cramps of that magnitude are a medical emergency and warrant a trip to the emergency department. Granted, the spasms could be caused by a number of other disorders; however, I don’t know many people willing to make that kind of call on scene?

It’s always difficult to scrutinize another health care provider’s performance in a situation such as this one, especially when you weren’t present. However, these are the cases we can all learn something from, and helps reiterate to always err on the side of the patients safety.

Edited April 14, 2009 by emsboy_2000

[Doczilla]

So what this kid had some MASSIVE electrolyte imbalance which caused a cardiac arrest hmm ..... ok sure I've heard of that happening but it's pretty gosh darn rare. I'd expect anybody THAT dehydrated to have some symptoms and ECG changes.

I was originally going to post a sarchastic question asking if a building fell on him or something because I've known this as "crush syndrome" but I looked in the journals, and sure enuf excessive muscule use (esp if dehydrated) can cause it. See here for the article

I can't say what I'd have done here but I sure as hell wouldn't get vascular access on this kid because he wanted it. If he couldnt sit still for more than a few seconds and was bitching about cramps I wouldn't leave him at home that's for sure!

With multiple empty water bottles on the counter, dilutional hyponatremia is a possibility. We see this in soldiers who overhydrate with water without taking in enough sodium through meals or their MREs. And it's not that rare. This kind of electrolyte imbalance is not evident on the EKG. Hydration with NS is indicated. The other concern would be rhabdomyolysis after extreme exercise leading to hyperkalemia, but a 3 lead EKG would not typically show this unless the potassium level was extremely high and the patient near death with a sinusoidal EKG trace.

What I can say about this is the FIRST thing I would do is hydrate him with NS. Not because he asked for it, but because it's indicated.

Re: the patient's right to refuse, it is difficult to put an exact line at where this kid is able to legally refuse. He doesn't meet the emancipation clauses that permit him to make his own decisions regarding treatment for STD, pregnancy, or drug abuse. At the same time, his decision making capacity is roughly that of an adult. This puts the medic in a difficult place.

The second issue is whether or not the medic had any indication of altered mental status. We don't REALLY know what the medics saw and interacted with on scene, so we can't say that from the invariably wrong news report.

'zilla

[emsboy_2000]

First of all, from a legal liability standpoint, you have to determine what the law considers a minor to be. Not all states share the same medical definition of what constitutes a minor. In California, for example, (where I’m from) it is illegal to release anyone under the age of eighteen with a medical complaint or condition. When the parents can’t be reached, it becomes the responsibility of the EMS personnel, and even law enforcement—if need be, to ensure the patient’s medical well-being. This unfortunate situation has to be analyzed in the context of the state if occurred in.

Secondly, from a professional medical standpoint, if the patient was experiencing full body cramps or spasms, wouldn’t that lead one to think that perhaps this kid might be suffering from severe dehydration? And, perhaps…need an ER visit! I’m not sure that advising a patient—in that condition—to continue hydrating with water and Gatorade is the best advice. Most patients with full body spasms due to dehydration are beyond the point of what water or Gatorade can resolve. By most medical texts I’ve come across, spasms or cramps of that magnitude are a medical emergency and warrant a trip to the emergency department. Granted, the spasms could be caused by a number of other disorders; however, I don’t know many people willing to make that kind of call on scene?

It’s always difficult to scrutinize another health care provider’s performance in a situation such as this one, especially when you weren’t present. However, these are the cases we can all learn something from, and help reiterate to always err on the side of the patients safety.

[brentoli]

emsboy_2000

I'm not trying to call you out, but why did you quote your whole post? Seriously, I read it a couple of times and can't fiqure it out, can you elaborate?

[Richard B the EMT]

FRom the website of the New York State Department of Health, on the subject of Imancipated Minors.

Check your state/provence/national protocols, as they, local to you, might be different.

<H1 id=pagetitle>

<H1 id=pagetitle>Patients Care and Consent for Minors</H1>Bureau of EMS Policy StatementPolicy Statement #99-09Date11/24/99SubjectRe: Patients Care and Consent for MinorsSupercedes/UpdatesIt is the purpose of this policy to clarify the legal issues surrounding consent to medical care and/or the refusal of care by minors in the pre-hospital EMS setting.

Emergency Medical Services (EMS)providers are often presented with patients who are considered by law to be minors. The issue of providing care and/or the patient's right to refuse care becomes a complex circumstance EMS providers must address. In the prehospital situation the issue at hand is not usually providing care but rather the failure to treat.

Legal Background

A minor, in New York State, is defined as a person who is under eighteen (18) years of age.

This is defined by the General Obligations Law § 1-202, Domestic Relations Law § 2 and Public Health Law § 2504. Under this section of Public Health Law, a person who is eighteen or older may give effective consent for health care.

Public Health Law § 2504

Enabling certain persons to consent for certain medical, dental, health and hospital services.

1. Any person who is eighteen years of age or older, or is the parent of a child or has married, may give effective consent for medical, dental, health and hospital services for himself or herself, and the consent of no other person shall be necessary.

2. Any person who has been married or who has borne a child may give effective consent for medical, dental, health and hospital services for his or her child.

3. Any person who is pregnant may give effective consent for medical, dental, health and hospital services relating to prenatal care.

4. Medical, dental, health and hospital services may be rendered to persons of any age without the consent of a parent or legal guardian when, in the physician's judgment an emergency exists and the person is in immediate need of medical attention and an attempt to secure consent would result in delay of treatment which would increase the risk to the person's life or health.

5. Anyone who acts in good faith based on the representation by a person that he is eligible to consent pursuant to the terms of this section shall be deemed to have received effective consent.

In addition to these provisions for health care consent by 'emancipated' individuals, there are other statutory provisions for minors who are in military service or are seeking treatment for AIDS (PHL § 2781) and other sexually transmitted diseases (PHL § 2305). So long as the individual is a minor, the presumption is that he or she is not emancipated and the burden of proof rests on the individual asserting it.

The Mental Hygiene Law also addresses consent but for situations not usually within the scope of EMS. Additionally in § 9.41 it permits peace and police officers to 'direct the removal of any person to a hospital who is conducting himself in such a manner which is likely to result in serious harm to himself or others'.

Other governmental agencies, such as law enforcement, mental health or corrections, may have legal definitions for individuals under eighteen that describe specific rights or responsibilities. Unfortunately, these do not impact health care decisions including the ability to consent or refuse care in the prehospital setting.

Refusal of Medical Assistance (RMA)

An individual who is legally a minor cannot give effective legal/informed consent to treatment and therefore, conversely, cannot legally refuse treatment.

Documentation

Complete an assessment of the patient. Fully document all circumstances including subjective and objective findings, attempts to contact parents, note any objections or refusals by the patient and all other pertinent situational facts. Include witness statements. Always consider contacting medical control for assistance.

Collaboration with other Agencies

EMS agencies are advised to work with hospital administrators, local law enforcement agencies, school administrators and community youth group leaders to develop policies and procedures to best serve the medical needs of minors in time of an emergency.

There are alternatives to EMS and hospitals for custody and supervision of minors. An uninjured child may be supervised by law enforcement personnel or a school or activity (soccer, etc.) supervisor until a parent is contacted. In some situations, a responsible adult (grandparent, aunt, brother, etc.) with the child can assist in the decisions making.

EMS agencies should work with local youth activities to ensure they have made plans to contact parents, have provided consent to treatment forms or have other permissions in place for the children in their supervision.

EMS agencies also need to work and plan with all police agencies for those situations involving minors, particularly those who are not injured and do not require hospitalization. Local and state police have broad powers which can be used to protect minors and facilitate custody.

However, all else failing, the EMS provider may remain responsible for providing care and/or transportation of a minor to a hospital.

EMS Agency Protocols

Agency policies and regional BLS and ALS protocol sets can contain guidance for treating minors in the prehospital setting. Contacting medical control is always an acceptable option for EMS providers faced with uncertain situations. Medical control may be able to influence the situation, even if it can't change the consent options.

Recommendations

EMS providers may find themselves responsible for minors, in situations they have been called to when there is no parent or guardian present or reachable.

Although it is easy to determine a legal definition of a minor, the responsibility to treat or release is a much more complex legal, ethical, social and public relations problem. The

nature of children and their special needs coupled with their inability to legally give informed consent, present special and unique matters for EMS personnel to consider and evaluate. Careful assessment, decision making and documentation are key as is discussion and planning with other agencies.

Act in the best interest of the patient — EMS providers must strike a balance between abandoning the patient and forcing care. There may be instances in which a minor appears mature enough to make an independent judgment, however legally, the minor is unable to make a decision. Always contact medical control for assistance if there is any question!

Common sense, prior agreements, sufficient documentation, and acting in the best interest of the patient must prevail.

Issued by: John J. Clair, Associate Director - Operations

Authorized by: Edward G. Wronski, Director

</H1><A name=skiptocontent> Edited April 14, 2009 by Richard B the EMT

[emsboy_2000]

emsboy_2000

I'm not trying to call you out, but why did you quote your whole post? Seriously, I read it a couple of times and can't fiqure it out, can you elaborate?

I did quote my entire post, didn't I? I'm still trying to figure out how that happened. It was accidental...I guess.

[Riblett]

I have been called a numbers Nazi many times, border line cook book paramedic because I am still green enough to see mostly black and white. But even to me this seems to be a gray area. I worked two of Orange's neighboring counties when this incident occured. The paramedic involved resigned after he received numerous death threats regarding this incident. Secondly, Dr. Brice the system medical director suspended his right to practice as a medic in the system before NC OEMS ruled on the case.

First of all, his right to practice was suspended based on failure to follow protocol. The OEMS report details seven Orange Co protocols he did not follow. Some of them are valid. But he couldn't hold the guy down to take and EKG or orthostatics if he refused. I mean, he weighed 250+ pounds and there is that little detail called assault and battery. If Fraley refused to sit down for the orthostatics or EKG then what was he supposed to do? That is not a protocol breach. So Brice can bitch about him not doing that all she wants, it just shows that she has not concept of prehospital medicine besides what she sees from behind a desk. It cites that he didn't follow the refusal of care protocol. on the refusal form because he didn't check the box stating the recommended time frame for him to follow up with a physician, immediately vs four hours vs 24 etc, but the Orange Co protocols does not specifically list age requirements for signing a refusal form. These details can all be read in the NC Office of EMS findings report referenced below.

Secondly, the news writer either didn't read the autopsy report he wrote about or didn't have any concept of what it meant. Fraleys autopsy report states that there were no indications or clinical signs of dehydration and that his post mortem electrolyte panel was within normal limits. Perhaps Doczilla could chime in on this one for us, but it doesn't seem like a fatal massive electrolyte imbalance would return to completely within normal limits post mortem. It could, I don't know. The autopsy findings seem more suggestive of a fatal asthma attack considering the findings of the pulmonary structures. If he did experience a fatal asthma attack after they left, that was a tragic coincidence which was not predictable based on the paramedics clinical findings. You can't blame a medical provider for letting you sign a refusal form for one complaint when you later experience a negative outcome from another that wasn't present at the time. Given that if he had been taken to the hospital for the possible dehydration and happened to experience an asthma attack or cardiac arrhythmia he might have survived, that makes this a sad situation but still not the fault of the medic. Even if he had been taken to the ER when his vitals, EKG, and labs came back normal they would have simply sent him home with a prescription for a muscle relaxant and instructions to increase PO intake, maybe even before the incident occured.

Additionally there is the issue of consent. The protocols don't specify age requirements to refuse treatment and transport. But if you make the determination that he was a minor and not able to refuse treatment, then according to the NC minor consent laws, he would not be old enough to consent to treatment and transport either, for a nonemergent condition. Since he was complaining of muscle cramps and all his vitals were within normal limits, it probably would not cross into the threshold of what the law defines as being an emergency condition that delay in care to contact parents for consent would have negative outcome. All that aside, being that most of us are not doctors or lawyers, we have a phone or radio to contact medical control for this issues like this, which he should have done. How do you spell medical control...C-Y-A.....ok rant finished.

Autopsy report: http://www.wral.com/asset/news/local/2009/...195/Autopsy.swf

NC Office of EMS investigative findings report: http://www.wral.com/asset/news/local/2009/...5961/fraley.swf

Orange County EMS protocols link is in Mateo's earlier posting

Edited June 3, 2009 by Riblett