Vermont Medic loses license over fatal crash

[Just Plain Ruff]

I was looking for some varied opinions on this but I'll throw mine in.

Pericardiocentesis - not allowed in vermont - done by this guy - yes lose your license

2 medications out of scope for the management of airway - this guy gave em - out of scope - yes lose your license.

letting the patients sister take direct patient care when there was obviously enough people there (especially when he could send another medic into the hospital) FAIL but doesn't qualify to lose license. just stupid

And to delay transport waiting on a doctor to come perform pericardiocentesis - FAIL MAJOR FAIL FAIL FAIL FAIL

I'm sorry but this medic was a direct (maybe not the complete and utter cause) cause of the death of this patient. Everything he did made it worse and he helped in my opinion hasten this patients entry into the afterlife.

And although I feel sorry that this guy lost his license and such, I'm not going to lose an ounce of sleep over it because it was definately a deserved loss. Besides, I hear McDonalds or Jack in the Box actually pays better than most EMS systems in Vermont.

Losing his license was and is the least of his worries. He now stands to lose his house, his car, his dog and his everything else all because he wanted to practice cowboy medicine and show off what he knew and what he could do.

To say that "I may lose my license" and then go ahead and do the procedure demonstrates to me a conscious disregard for the patients well being. There is a reason why a certain skill isn't allowed in a certain state.

I mean I've been taught to do a pericardiocentesis in medic school, doesn't mean that I remember how to do it and that I even should do it.

How many of us medics have even treated a patient who needed one?

Does my ambulance even carry a needle long enough for the procedure? I really don't think so?

How many of your ambulances out there carries a long enough needle to do the procedure. I'd be interested in hearing back from those out there? Do you have a 4 inch or so long needle in your trauma kit?

Edited October 1, 2012 by Captain ToHellWithItAll

[scratrat]

Having the training and experience is highly relevant and also makes a substantial difference in what laws, if any, were actually broken. Practising beyond your scope when you have the educational background to know what you're doing compared to seeing it on TV once. It's the difference between stupidity and incompetence.

I respectfully disagree. I could have been taught procedures in Florida that are illegal in New Jersey. In Florida, I could do a LOT including RSI without consulting my physician. In New Jersey, you'd kiss your license good bye. Just because you are taught a skill set in one area, does not mean that you can practice it everywhere!!

Even after becoming a paramedic, I (regrettably) continued with a volunteer BLS service. In this state, paramedics must be operated under the direction of a medical center. BLS entities are not. Meaning, even though I was a paramedic, I could only function as an EMT while on those rigs. I could not start IV's, etc and could have lost my license if I did even though I was trained and certified to do it.

Practicing outside your scope is irrelevant to your training. If the State says "You can't do this", then you can't do it, regardless of your education and background. You have to abide by the laws governing your particular State and that particular employer. You cannot justify saying, well in this state we did this. They don't want to hear that.

Edited October 1, 2012 by scratrat

[island emt]

2 Things will do him in.

Operating outside the allowed Paramedic scope of practice

Not acknowledging the DR's order to transport immediately to the nearby hospital ER where the procedure , if needed could be preformed by a licensed MD.

Those two items are enough to deny relicensing in most states.

[systemet]

I have a little bit of a different take on this.

(1) This calls sounds like a nightmare. Any scene where one of the responding crew is a relative of the patient and they are acutely sick has all sort of potential to become a massive cluster. In an ideal world there would be enough people on scene to remove any patient care responsibilities from that person, and have someone take over their role. Even with them still present on scene, with no patient care responsibilities, it's going to add an additional dynamic to an already difficult and stressful situation.

(2) I'd like to know more about why he felt the pericardialcentesis was indicated, before I judge him too harshly. I realise that from a legal perspective, that if you perform outside of your scope of practice, you're done. But from a peer-review or professional conduct perspective I'd like to know first:

* Did he believe that the percardialcentesis was a lifesaving measure that needed to be performed in the field?

* Was this belief reasonable given the available information?

* Had he had the necessary training to perform this intervention in a competent manner?

Scope of practice is designed to protect the patient from poorly-trained or untrained providers. If he was adequately trained to perform the procedure and it was indicated, as ArticKat pointed out, it's a very different scenario to just being a cowboy. Perhaps the violation of the scope of practice was in the patient's best interest?

This also speaks a little to the particular silliness in many regions, including the US and Canada, of having multiple scopes of practice and training standards within the same country.

(3) I'd like to know more about the airway management medications used. Given what we know about trauma care it seems unlikely that a field RSI (presumably in this case, it was some form of non-RSI approach with sedation?) would be justified if they're close to the ER.

I think it's really difficult to judge someone without full knowledge of the situation. I'm also particularly sensitive to the difficulties of dealing with a acutely sick patient who is known to a crew member.

If there isn't a pattern of behaviour that indicates a consistent lack of judgment, I think nonrenewal is very heavy handed for a first offence. I doubt a physician would be treated as harshly in a comparable situation, and don't see why we should be some continually willing to throw away paramedics instead of remediating them just because the training time and cost of training one is cheaper.

edit: formatting of bullet points.

Edited October 2, 2012 by systemet

[Richard B the EMT]

This seems a bit excessive to me. There must have been additional unmentioned historical issues with this medic for the State to act in such a heavy handed manner. Up here for a first offence like this he'd likely end up with a fine and a requirement for remedial education.

Then again, it is rather unique because the story makes it sound like the medic's ego was the cause of death.

Per the newspaper article...

According to an EMS report, Hall performed a pericardiocentisis, an invasive procedure that involves using a needle and catheter to remove fluid from the sac around the heart. The report notes that Hall, prior to performing the procedure, stated that he may "lose his license for this." Other paramedics that were on the scene testified that they cautioned Hall not to perform the procedure.

"Based on the multi-factorial issues described above, coupled with the fact that Paramedic G. Hall knowingly performed a procedure that was outside his scope and was at that time aware of the potential implications for his actions according to witness testimony, it is therefore recommended that Paramedic G. Hall’s application to VDH for license renewal be rejected," the report states.

After so blatently operating outside of scope, knowing he was going out of scope, and admonished by others on his level of scope on the scene not to do it, I'm surprised he wasn't bounced after the Vermont DoH reviewed his actions, let alone wait until he attempted to renew his license/certification.

What I didn't see in the article was if he was attempting to treat under On Line Medical Control's direct advisement. I admit I don't know where or when it happened, but 2 Paramedics, operating out of scope, but under directions from their OLMC, literally step by step, performed a Cesarean delivery of a viable fetus from it's deceased mother. Those 2 initially were suspended, but the OLMC Doctor went on record at the DoH hearing, indicating he trusted the 2 Paramedics to exactly follow his instructions, resulting in the successful delivery and saving of the baby's life (Unknown what the result would have been if the baby had NOT survived, for either the Paramedics or the Doctor).

[Just Plain Ruff]

The cesarean section may have actually been a partner of mine Richard. I was not there but I know the entire story and it's outcome.

As for the out of scope, unfortunately a patient died as a result of (at least partially) the medics actions and although we don't know the entire story, we know enough to say that the medic was a proximal cause of this patients death. The trauma is really what killed him but could he have been saved had the medic not have tried this procedure, not one time but twice (if I read right).

The hospital they were going to was very close, I believe they could see it.

And remediation, is possible but seriously, this is a horrible outcome that is not redeemable in the eyes of the state of Vermont.

They aren't throwing him under the bus so to speak, he still has his license in the other state. But I'm not sure if he's going to have any Ass to move when he gets done with court.

This is more than likley a career ending decision, all based on "I might lose my license" thought lines.

I'll bet he's a good medic, but yes, one bad decision can be the deal breaker. One bad decision can sometimes, and sometimes it should be the deciding factor of making a career change.

Who's to say he won't have the attitude if he "I got away with it that one time, I can get away with it again"

[eb1040]

I still have a problem with this collision being almost at the end of the driveway of the hospital. If you have time to send a Paramedic up to the hospital, you had time to take that patient there. If there was entrappment or some other reason the patient could not be moved, the doctor should have been requested immediately or this made clear during the repeated communications.

This is the location according to the newspaper. Weeks St. and Dewey St. intersection is just north of the hospital drive.

https://maps.google.com/maps?hl=en&ie=UTF-8&q=southwestern+vermont+hospital+bennington&fb=1&gl=us&hq=southwestern+vermont+hospital&hnear=0x89e096592f93e6d1:0x36093b92bf32d7c0,Bennington,+VT&cid=0,0,8019787768181511999&ei=7BNrULWrF-KliQKysoHQDA&ved=0CH0Q_BIwAA

[island emt]

systemet: Doesn't matter what his training is. In most states there is an established scope of practice , which is what we all have to follow.

These rules are determined by a medical review committee at the state level and to venture outside of them puts your license to practice at risk.

In this case the medic knowingly went outside the rules and knew he was doing so as witnessed by others on scene. He stated he was putting his license at risk according to the article & witness statements.

Then he basically ignored the ER doctors repeated request to transport immediately to the ER a short distance away.

This is a blatant failure to operate under the license parameters of his scope of practice.

If the DR had advised him to do the procedure , then he might have a leg to stand on , as the battle would be between the state & the DR. for giving him those orders.

Yes the pt may have been critically injured and to the best of the medics knowledge & judgement needed the pariocardicentesis done to relieve pressure on the heart. It doesn't matter if he was right or wrong on his diagnosis, what matters is the foray outside of protocols.

Knowledge of a medical procedure can only go so far , before you cross over the line of whats legal for you to do.

I truly believe the medic in question felt it was the correct thing to do and was willing to take the risk of both his license and his career in an attempt to save the patients life.

After looking at the map: they were within 150 yards of the emergency room door.

edit for spelling correction.

Edited October 2, 2012 by island emt

[eb1040]

But, on the other hand, if he felt confident in doing the procedure why send a Paramedic to the hospital for the doctor to come outside and do the pericardiocentisis?

Sending another paramedic to the emergency department at Southwestern Vermont Medical Center to request that a physician come to the scene to perform a pericardiocentisis. The physician requested "multiple times" that the patient be transported to the hospital.

The hospital staff and the other Paramedics must have been beside themselves watching this unfold. You have to wonder what his state of mind was at this time with so many disagreeing with his decision.

The timeline would be interesting to see.

Edited October 2, 2012 by eb1040

[Just Plain Ruff]

I can imagine that this was a case of tunnel vision going into a collapsing tunnel. You go down a path and come hell or high water you are completing that journey. Once you go down the road there may have been no turning back in the mind of the medic and he wasn't listening to anyone but the voice inside of his head that said "do it do it, save the life, just do it"

Who knows what the medic was thinking but I have to agee that he probably thought that the patients life was worth more than his license. Well unfortunately he is realizing what his stand is costing him.

What a painful and expensive lesson for this guy to learn.