Fla. mom awarded $10M in ambulance birth lawsuit

[VentMedic]

Vent, I won't speak for JP (he seems to be able to do that just fine) but I am well aware of our ability to save 23, 24, 25 week wheezers and seizers. I am not arguing the point of whether this baby was viable. My first comment to you was to provide a source for your statistics. If you are going to provide statistics to further your arguement the onus is on you to provide the reference. I am not saying your statistics are wrong, you just need to provide a reference.

By your "wheezer and seizer" remark this will probably be a waste of my time. It seems you already have your opinion about any efforts to save these babies.

Doctor, in the past 3 years I have posted link after link about scientific studies and statistics. Do you know what I found? I wasted my time because very few people who reply to my posts never read the links and really don't give a rat's ass about stats or ANY of the information in those links unless it has been verified by JEMS.

Doctor, this is probably one of the easiest piece of information to research. You can borrow an NRP book from an L&D nurse or RT if your hospital has L&D to look at the references listed in it. You can also talk to a neonatalogist from a level 3 NICU and they will be more than happy to share THEIR stats with you. The advancements in that field is something many are proud of and it is constantly evolving to improve with new technology, meds and lobbying for better prenatal care by way of outreach clinics. Thus, I am just surprised that someone who has access to this information wouldn't understand the factors when stats are quoted at 50 - 80% with the low end being less than ideal and the high end being ideal. In the part of Florida where this took place, for over 30 years they have had access to Level 3 nurseries and transport teams that can provide high level of care. Unfortunately many Paramedics are not even aware of how they are utilized because the teams fly or drive in by way of their own vehicles with their own pilots and drivers who are generally from a transport division of the hospital and not an EMT. If an ambulance is contracted to transport a specialty team, they are given very little information so the drive will be safer with the EMT(P) not feeling the stress of a critical transport. So when a Paramedic gets a call like this, those who are young and inexperienced may think it is the first time this has ever happened and its time for them to throw caution into the wind and spring into super medic mode to save everyone without realizing they are risking everyone including themselves. Look at the many threads we've had on this forum about the dangers and ineffectiveness of L&S/speed. You now have a situation where they will be running fast for almost 70 miles with a pregnant woman about to give birth in the back without much expertise and meds to calm either or prepare them for a high risk transport if that was even possible. I want some to find out what resources they have in their area and not put the patient(s) or themselves at high risk by not even knowing what equipment or expertise they should have.

I am again going to waste my time and put up links with stats that no one gives a rats ass about and that probably includes you DOCTOR since you picked one number out of all the other information to bitch about. YOu also seem to have a difference of opinion about Paramedics being cowboys since you may have been one. Maybe your area does not have any level 3 NICUs or any type of advanced CCT, Specialty or Flight and diesel is still the only way to transport. I don't know why you have chosen to just keep coming back at me when I explained in other posts about how the 50 - 80% stats can be derived. Also if your area does not have access to ANY of the advanced care and transport you statistics may be much lower and your area may not even attempt to work any baby less than 27 weeks. That would be a shame since our team can fly several hours to another country or the islands and get a premature baby that has been stabilized in a hospital with very minimal resources. One would think that should be possible here in most parts of the U.S. with the exceptions of some regions.

I hope you can appreciate the differences in the research since my area does not give up on the 25 week gestation baby regardless of where they were born until the tests are in and then the parents can be part of an informed decision. However, these babies do deserve a chance and their survival rate should not diminished because an over eager ambulance company does not even begin to know the basic preparation for a 70 mile transport. For this incident, the statistics will be very low since the baby was not even given a chance due to lack of warmth, which greatly affects resuscitation, and lack of an advanced airway to adequately provide oxygen and ventilation which again is made very clear in even a simple course like NRP. So it doesn't really matter about the national stats since this baby was not given a chance by MEDICAL PROFESSIONALS.

I would also hope you can get past the urge to encourage cowboy medicine by taking unnecessary risks on an IFT in an area where there are several alternatives and resources.

Here is a link to the March of Dimes website which has decent general information

http://www.marchofdimes.com/professionals/14332_1157.asp#head5

If you look at the reference section you will see where they got their numbers from.

Here's an interesting study from London. I'm not posting the actually research article since it seems you or someone else who is even remotely interested in preemie stats probably can not pull it up on their home computer. If you also look at some of the research in other countries, you will find the U.S. is lagging in survival and minimal defects as well as having a higher infant mortality rate.

http://www.sciencecentric.com/news/article.php?q=08020114

The research shows that the overall rates of survival for infants born alive between 22 and 25 weeks of gestation and admitted to the neonatal unit at UCLH increased from 32 per cent to 71 per cent between 1981 and 2000. This includes babies born in other hospitals and transferred to UCH for intensive care.

The researchers also looked at the survival of infants born at the hospital between 1991 and 2000, including those born at 22-25 weeks gestation who died before they reached intensive care. The survival rate for this group at the end of the study period was 69 per cent - compared to 71 per cent for the group that included only babies admitted to the neonatal unit. This suggests that the results were not solely a consequence of selecting infants with a higher chance of survival.

Canadian study for the early to mid 1990s for survivability of 24/25 week gestations.

http://www.ncbi.nlm.nih.gov/pubmed/12135208

Here's a study published in 1998 with data taken several years before the Volusia incident.

http://pediatrics.aappublications.org/cgi/content/full/102/2/e20

Again, if you look at the bottom of that article, you will find several more references to studies.

Here's a link to many studies by way of google scholar.

http://scholar.google.com/scholar?q=neonatal+survival+statistics&hl=en&as_sdt=0&as_vis=1&oi=scholart

Also, I posted a link to the "baby first" website in this thread that explains what factors affect infant survival and it still pertains to what is done initially by the MEDICAL PROFESSIONALS. Failure to do even the basics correctly like warmth and oxygenation/ventilation (both of which just about any ED in the U.S. should have the capability of doing) will make whatever stats quoted for survival useless if the baby was not even given the chance.

I am not saying your statistics are wrong, you just need to provide a reference. I think 95.2246% of the people on this site would agree.

Nice responses...however I had to give 2 thumbs up for this gem.

Look at how many links to articles, references and statistics I have posted over the past 3 years only to find that those who replied to these posts never even bothered to read the articles. Do you honestly think that is a fair statement made by ERdoc? However, it seems you also have not bothered to read any of the links to research I have posted over the past few year either. So as I stated earlier, I just waste my time posting research stats. And, this is something one can easily google.

For some here, if it isn't in JEMS there is just no truth to it.

Edited April 12, 2010 by VentMedic

[akflightmedic]

Nice of you to make assumptions about what I do or do not read.

My thumbs up was for the humor which I am a huge fan of. The "statistic" which he inserted while asking you for a statistic is funny. It breaks the tension...

[VentMedic]

There are a lot of details of this case missing. Making some assumptions, it would seem that the sending and recieving docs felt the patient would make the transfer without delivering, or they would have planned for that eventuality. The EMS crew that arrived likely were assured of that as well. The sending doc must have felt this or would never have sent the woman with a crew of 2, a driver and a medic. With one medic in the back with 2 patients, I have a hard time faulting him/her for not intubating the kid. Securing an ETT in a 25 weeker in a moving truck is difficult at best, not to mention other resus that may need to take place. Even the most skilled neonatologist would be very stressed managing this kid solo in a moving ambulance. I have a hard time faulting the ambulance company for the outcome, I believe it is the sending/recieving docs who decide what level of transfer is appropriate.

The sending doctor and hospital realized their errors and did not want a jury trial.

Even critical care and flight teams that are considered advanced level care can abort a transport if they feel the patient can not be moved safely by their resources. A Paramedic ambulance definitely can in an area where there are other resources. Yes, the fault falls to the doctor but the Paramedic failed to inform they were not the best option for transport or realize they were in over their heads. Maybe the eager cowboy attitude also gave the doctor a false sense of security that the Paramedic was a super hero with a "sure, no problem" attitude.

Just on the fact that this ambulance could not even provide the basics for neonatal resuscition puts fault in their corner and their failure to realize their actions or inaction contributed to the outcome of this baby when the other parties already settled can be taken as just arrogance and ignorance. Arrogance will never win over a jury and ignorance is not a good defense.

It will also be interesting when another major case of EVAC's goes to court. If they go with a jury, I don't believe that case will end well either especially given the age of the woman and the Paramedic's alleged comments to the patient.

[p3medic]

My point is that if two docs on either end of this transfer feel it is unlikely that a need for additional resources would be needed, then the medic, who I know nothing about, might feel comfortable with the transfer. The fact that things went poorly is why they are in the legal situation they are in. I honestly can't fault the medic for not refusing the transfer assuming the doctors on either end realized the level of care doing the transfer and they felt no other resources were needed. For every case like this there are probably 1,000 that are uneventful. I do agree that in hindsight going to trial was a bad idea. Just curious, given the information we know about the patient, prior to transfer, what do you think the proper crew configuration and mode of transport should have been? Honest question.

[VentMedic]

Nice of you to make assumptions about what I do or do not read.

My thumbs up was for the humor which I am a huge fan of. The "statistic" which he inserted while asking you for a statistic is funny. It breaks the tension...

My assumption came very easily when you agreed at a statement bashing me for a statistic that was initially posted in the JEMS article which was linked by Dust and also a newsfeed article. Did either you or ERdoc bother to email the author of that article to post his source for that statistic?

This is a serious conversation and I don't appreicate you bashing me for something that has directly affected the way IFT transport is provided here in Florida. And, again, if you had bothered to read a couple of my links, you would see what exactly I have referred to.

Edited April 12, 2010 by VentMedic

[VentMedic]

My point is that if two docs on either end of this transfer feel it is unlikely that a need for additional resources would be needed, then the medic, who I know nothing about, might feel comfortable with the transfer. The fact that things went poorly is why they are in the legal situation they are in. I honestly can't fault the medic for not refusing the transfer assuming the doctors on either end realized the level of care doing the transfer and they felt no other resources were needed. For every case like this there are probably 1,000 that are uneventful. I do agree that in hindsight going to trial was a bad idea. Just curious, given the information we know about the patient, prior to transfer, what do you think the proper crew configuration and mode of transport should have been? Honest question.

Let me tell you how the conversation would have gone:

ED physician to OB at higher level facility: Can you accept a maternal transfer with 25/26 week premature labor?

OB: "Sure, can you arrange for transfer or do you need us to send out our team?"

ED physician: "We have a Paramedic ambulance that states they are qualified for this transfer."

Or, the OB assumed the sending doctor was utilizing one of the more advanced teams to transport the patient such as those that may have RN/RN crews with a variety of experience.

ED physican to ALS ambulance: "Can you take a woman in labor with a 25/26 week gestation baby."

Paramedic: "Sure no problem. Our scope of practice states we can deliver a baby and intubate/resuscitate."

Thus, the ED physician may not have known the questions to ask or assumed too much of the Paramdics by the way they agreed to the transport. He may have thought if they weren't qualified, they would have refused as teams with more expertise may have done with other patients after weighing the risks.

If a neonatalogist had also been consulted, it would have been advised to deliver the baby and when birth was closer, they would have put their team enroute. This ED has the capability of maintaining basic life support of an infant. For maternal/infant transports we do not rely on "hindsight" except to learn from past mistakes. We now have networks, teams and state statutes in place for all health care professions that pertain to appropriate transfer of these patients. These transports have been happening for many years so a lot of lessons have been learned. It is unfortunate when the ball gets dropped and someone in that mess should have questioned the appropriateness before this took place. I'm sure (in fact I am very sure) that Fish Hospital has re-educated its physicians and licensed staff. I would only hope EVAC has done the same but if they can not see where they could have done things differently, nothing will be learned and it is actually the EMS providers that will suffer from this mentality.

This was also not just a run across town where they might have successly gotten the mother to the other hospital. This was a 70 mile transfer without the appropriate skills and equipment.

If you checked out your truck in the morning and found your ETI bag and cardiac monitor were missing, would you accept even a cross town ALS IFT? Would you not be expected to be held accountable by the hospitals to provide at least the bare minimum required for that transport as ALS? Just because this is a 25 week baby and some assume it will not survive or can write off any consequences as predictable, does not mean that baby does not deserve a chance. I have seen many 25 weekers grow to have no deficits and one may never know they were a preemie. Several of those I picked up at much smaller hospitals in very rural areas where the mother just came in to deliver without realizing the hospital did not have a L&D.

If you have never had much contact with a specialty team or a specialty hospital, you may not understand the differences in the level of care. For both adults and kids, we will initiate meds that are within our guidelines and protocols that the physician may not have or risked discontinuing certain drips because they thought we were just like the regular ALS trucks and could not take certain meds. We also look at lab values and CXRs that might be of concern for a long distance transport. We will trust the sending doctor just so far and will rely on the expertise of our medical director and the rec'g physician. They wrote our protocols and guidelines as well as trained/educated us for these transports.

Since this has happened Florida has been rewriting its IFT statutes to allow the higher level of care physician determine the appropriate transport and not an ED physician who may not know not all ambulances are created equal. For any transport involving a baby, the Paramedic must meet experience requirements even if an experienced RN is accompanying.

This is an example of another case and you can see how extensive the care can become. However, you must be able to prove as a provider that you met the requirements to at least provide oxygen even if the lungs are diseased.

http://www.5dca.org/Opinions/Opin2008/102708/5D07-1806.op.pdf

Florida (401.252)

(2) A licensed basic or advanced life support service may conduct interfacility transfers in a permitted ambulance if the patient's treating physician certifies that the transfer is medically appropriate and the physician provides reasonable transfer orders. An interfacility transfer must be conducted in a permitted ambulance if it is determined that the patient needs, or is likely to need, medical attention during transport. If the emergency medical technician or paramedic believes the level of patient care required during the transfer is beyond his or her capability, the medical director, or his or her designee, must be contacted for clearance prior to conducting the transfer. If necessary, the medical director, or his or her designee, shall attempt to contact the treating physician for consultation to determine the appropriateness of the transfer.

However, in Florida, for babies less than 28 days of age, they are considered neonatal transports and these requirments must be meet for IFT. No more emotional cowboy scoop and runs by EMS ambulances.

Click on: Notice/Adopted

Note on this document as to how the wording has changed especially about "ALS" ambulance and sending/receiving physician.

https://www.flrules.org/gateway/readFile.asp?sid=2&tid=7331471&type=1&File=64J-1.001.htm

I had also posted this link in an earlier post.

As I have stated before, this is a good time to have a converstion with your medical director. Do NOT take just take the advice from those who "want to do the right thing but have no clue what it might be but running real fast seems right". If your decision is a bad one, your medical director will end up with the mess in his/her lap.

Edited April 12, 2010 by VentMedic

[akflightmedic]

My assumption came very easily when you agreed at a statement bashing me for a statistic that was initially posted in the JEMS article which was linked by Dust and also a newsfeed article. Did either you or ERdoc bother to email the author of that article to post his source for that statistic?

This is a serious conversation and I don't appreicate you bashing me for something that has directly affected the way IFT transport is provided here in Florida. And, again, if you had bothered to read a couple of my links, you would see what exactly I have referred to.

Can you quote where I "bashed" you? As I said in my explanation which you clearly did NOT read or you would not have written what you did also displays your lack of consideration to other people's comments.

I said I liked the statistic that he made up to prove his point. I did not say I agreed with it, but I did like the humor. There is a difference and I felt it should be recognized because in any debate worth following, there will always be points for both sides which deserve complimenting.

I did not see you complaining when I complimented you earlier, nor when I gave you "points" for a good post.

[chbare]

There is no reason to loose the plot over this stuff or assume "bashing."

Take care,

chbare.

[ERDoc]

Weezers and seizers was a term of endearment I learned from one of the NICU attendings at one of the hospital where I work. We have a 67 bed, Level III NICU that is the only one in western Michigan and the upper penninsula so we do know a few things about premies. As for transport, we have our own helicopter service which is staffed by doctors and nurses. We do not have a ground transport service but have a private service such as AMR pick up the team. I, personally, was never a paramedic, only an EMT and I admit I had a cowboy tendency when I was an EMT. It scares me now, knowing how much I didn't know.

As for issue of providing links, when you post a statistic to further your argument, it is up to you to provide a source, regardless of how many people do or do not look at it. I agree that it is foolish to keep going back and forth on this, so let's agree to end it here. As for the JEMS link, I did not go to it. I, personally, do not look at much from JEMS. As for your other links in other posts, I have looked and them many times and have found them to be helpful and educational. Just because someone may not comment on a link you post does not mean they are not being looked at. Looking at your reputation, people obviously find your posts informative. I would encourage you to continue providing links. It only helps to prove that there may be hope for bringing education and not just training to EMS.

The onus of the transport is on the sending physician. The receiving physician has not evaluated the pt and can only base their decisions on what the sending physician says. I think the Florida lawmakers response to this incident is an uninformed kneejerk response (would you expect anything less from politicians). There are times when waiting for a fully staffed, more equipped ambulance to arrive may be detrimental to the patient. These situations are judgement calls and should not be legislated. This is where the art of medicine comes from. Some times judgement is wrong, there is no way to avoid that, including trying to legislate it away. Sometimes, there is nothing you can do to change the outcome. Let's say this kid had a fully staffed NICU transport, would the outcome have been different? There is no way to say but it is very possible. As I said before, how do we know this kids was not oxygen deprived while mom was laboring in the hospital waiting for the transfer. Would waiting another hour for a fully staffed unit to come have made the situation worse? As a sending physician, when I call for an ambulance I expect that the paramedic that takes my pt has met the qualifications to be a paramedic (although I do keep in mind that the guy who graduates last in his class is still called a paramedic).

[VentMedic]

Can you quote where I "bashed" you? As I said in my explanation which you clearly did NOT read or you would not have written what you did also displays your lack of consideration to other people's comments.

I said I liked the statistic that he made up to prove his point. I did not say I agreed with it, but I did like the humor. There is a difference and I felt it should be recognized because in any debate worth following, there will always be points for both sides which deserve complimenting.

I did not see you complaining when I complimented you earlier, nor when I gave you "points" for a good post.

Was I also supposed to write thank you for your compliment? I honestly did not believe it was necessary. However, when you agreed with ERdoc who again called me out to show proof to data that had already been mentioned in the JEMS article which is what I took apart, I did feel there was a need to provide a response and question your motive. You did not place a bunch of "smiley things" or provide any other indication that is was intended to be a joke.

This point system gives no indication of who gave what. If one had to actually give a reason for the point, either negative or positive, it might acutally mean something. It is way too easy for points to be given or taken away just as a popularity contest. It probably has nothing to do with the quality of the post.

Again, I will also make the statement that I clearly stated in my post that the 50% number came from JEMS. My argument around it does not mean you just write a baby off because of some 50/50 stat to justify the shortcomings of action or inaction.

Also, as pointed out in the JEMS article:

Quote

In 2003, the mortality and morbidity rate for this type of birth was 50%.

However, I will now highlight "this type of birth" from the JEMS quote.

VentMedic, on 11 April 2010 - 07:15 AM, said:

For goodness sakes JP! Do you not know how to search for neonatal statistics? The stats quotes at 50% came from JEMS. It just took a few quick checks to see where he pulled that number from on the internet. I never made any direct statement as to where he got that information because JEMS was not part of the trial. Just look at the reputable neonatal websites and you can read all about neonatal stats. I also take NRP which is full of fascinating stats in the reference section that makes taking the course over and over again worthwhile as they are being updated as medicine evolves.

I also told ERdoc that NRP provides references to the numbers. Since those stats are generally mentioned in the justification of having people trained in neonatal resuscitation and are collected from many sources, why should I did up more data for someone who should already be familiar with neonatal resuscitation as an ED doctor. Yes, I understand JP was probably just arguing blindly since as an EMT-B he has probably not had to take anything other than infant CPR. CPR also provides statistics about survivability from various sources that gather research from them. Thus, NRP is a good source to get stats from.

But JP still was not happy:

I honestly don't have the time right now to pour over statistics for your arguments. If you have easy access to the statistics, then just post them. You brought them to the table, it's your job to provide a citation. So until you decide to post the source, this is going to be decisively a [citation needed].

And then ERdoc is still not happy with the NRP reference for stats.

My first comment to you was to provide a source for your statistics. If you are going to provide statistics to further your arguement the onus is on you to provide the reference. I am not saying your statistics are wrong, you just need to provide a reference. I think 95.2246% of the people on this site would agree.

That is when you akflightmedic jumps in even though I mentioned NRP as a reference.

How many Paramedics here have not taken NRP and are relying solely on the little blip in the Paramedic textbooks to get them through the resuscitation of a neonate? Or, do some not see the differences between neonatal resuscitation and infant CPR? While NRP is only to demonstrate the process of resuscitation efforts and your employer should be the one to monitor competency, it still makes one aware of the differences. After reading some of the comments made on the forums discussing this, including here, it seems some may see no difference in the preparation or resuscitation of a term baby, an infant that is older than 28 days and that of a very premature baby.