Vermont Medic loses license over fatal crash

[scratrat]

(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.

And that crew member should have been immediately removed.

(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.

Completely irrelevant as to why its indicated. If you felt it was warranted, you should have immediately transported him to definitive care to have the procedure performed. There have been plenty of times where we've had traumas right outside the trauma centers doors, and I wasn't about to waste time performing a needle decompression. It sounds like this medic saw an opportunity to perform a skill and look like a "hot shot".

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?

Even if he did, he was not authorized to do it. So again, transport to definitive care. This isn't the TV shaw "ER"

* Was this belief reasonable given the available information?

Again irrelevant.

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

Not permitted to be performed at his level at that particular time, in that particular state. We have procedures and protocols and a scope of practice for a reason. You can't have gung ho people performing whatever skill they choose and then justifying it by saying "was he trained properly in another state even though it's not permissable here?" I'm permitted to perform suturing in my federal job. Let me try that on the ambulance and see what happens.

Scope of practice is designed to protect the patient from poorly-trained or untrained providers.

And to prevent practitioners from performing skills that are not authorized to do.

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?

Vermont, that State were it occured, does not train or allow it's paramedics to perform this procedure. It's not a different scenario at all. You are NOT permitted to perform said skill and you knew it, and broke it, and now there's a dead body. This only compounds the situation a little bit. Had the guy survived the ordeal, I said would have voted to gank his license.

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.

Agreed, however, that is moving forward somewhat and most States are adopting standarized protocols. Almost all paramedic programs are conformed to the NREMT standards. NONE of which include pericardiocentesis by the way.

[systemet]

And that crew member should have been immediately removed.

Not necessarily possible. We don't know if that person was part of the initial responding crew, or if they were interfering with patient care. Law enforcement, if they're even available, can't remove them without a valid reason.

Completely irrelevant as to why its indicated.

In a legal context, sure.

From a conduct & competency perspective, I think the situation is better if the treatment provided was indicated and that the person performing it was sufficiently trained / skilled.

Given the information on how close the trauma center was, and that a physician had directed them to transport, it sounds like their actions were probably inappropriate. There's just not a lot of information here to go on.

]You can't have gung ho people performing whatever skill they choose and then justifying it by saying "was he trained properly in another state even though it's not permissable here?"

No one is taking that position. What is being said, is that there's a difference between someone who is adequately trained in an out-of-scope procedure, performing it in an appropriate manner, in a situation where it's clearly indicated, and some random guy who decides to do something they read about in a book once.

]I'm permitted to perform suturing in my federal job. Let me try that on the ambulance and see what happens.

Suturing and pericardialcentesis are two completely different beasts. Suturing is almost never a life-saving procedure.

Scope of practice is designed to protect the patient from poorly-trained or untrained providers.

And to prevent practitioners from performing skills that are not authorized to do.

The scope of practice defines what you're not allowed to do. This is a tautology.

]It's not a different scenario at all. You are NOT permitted to perform said skill and you knew it, and broke it, and now there's a dead body. This only compounds the situation a little bit. Had the guy survived the ordeal, I said would have voted to gank his license.

I think that in this situation it's most likely that the patient died from the initial injuries, possibly compounded by a transport delay. If an autopsy shows that unskilled pericardialcentesis contributed, then there's additional problems here.

I would want to know more before voting to yank this guy's license, though. Mistakes get made in medicine, even at the highest level. You clearly see this as an arrogant provider doing something rash to impress their colleagues. If that's shown to be the case, it would influence my opinion as well.

The guy is already civilly and likely criminally liable here. Given the limited information here, they probably deserve to have some form of sanction and remediation. I'm just not convinced that taking away their livelihood fixes anything.

]Almost all paramedic programs are conformed to the NREMT standards. NONE of which include pericardiocentesis by the way.

But presumably the states that perform pericardialcentesis still train this during medic school, right?

I think a move towards standaridisation, while painful in the short term, is probably a good thing.

Edit : trying to get rid of the blue colour in my responses

Edit2: gave up.

Edited October 3, 2012 by systemet

[Arctickat]

I'm not saying this is what happened, but I'm gonna throw this out there.

The medic was partnered with the patient's sister. As is most cases, partners become close friends, confidants, and have intimate knowledge of one another's lives. As far as adult relationships go, many partnerships come second only to the marriage. No doubt she knew exactly his skill set and what he could do. So, when his best friend and partner realised that he could and has performed the skills that could save her brother's life the distraught EMT begged and pleaded her best friend to do everything possible to try to save her brother. Being her best friend, he was incapable of separating his emotions from his professionalism.

I have no doubt that this was a highly charged emotional scene and mistakes get made when emotions are involved, Just think of what it's like when we transport pediatrics, This call would have been much more stressful.

Did he make a stupid mistake and a poor judgement call? Hell yeah, but if you haven't been on a call where you've had your emotions override your professionalism yet, it's just a matter of time.

[Just Plain Ruff]

Arctic - I've been on just that call.

But I'm sorry, the error is just too great in this circumstance. No matter how you cut it the state has the rules for a reason. They say no pericardiocentesis - then you just don't do it.

I don't think they are trying to make an example out of this guy though.

There are certain rules that any place has that if you break them, you're gone.

Many workplaces have rules about not bringing your gun to work, or watching porn on the company computers - most places you will be fired for that.

The state has the rule that NO pericardiocentesis by a medic as it's WAY WAY outside his scope of practice in Vermont and when you do that procedure you will lose your license. Simple as that.

So remediation might be acceptable to some in this case, obviously to Vermont, it was not a viable alternative.

It truly sucks that he lost his livelihood, and in the heat of the moment, when the shit is hitting the fan and you are working to save the life of a patient, that's usually not in the forefront of your mind (it must have been for him though). He even said "I may lose my license for this" so my thought is that he was ready and willing to lose his license but I'll bet that he never thought the state would go that far.

But with so many witnesses and doctors who were probably pissed they didn't get to do the procedure, I'll bet the patient wasn't even to the morgue before someone at that hospital was on the phone with his company and another person was on the phone to the state of Vermont EMS bureau.

But let's not lose sight of the most important thing here, A cascade of events presented itself to this medic and crew that quickly escalated to the point where in the end, a man died. Did the medic cause his death? I don't know but the delay to definitive care which admittedly was only a block away, did not help.

One would hope that if this guys appeal is successful that he would take the lessons learned from this fiasco of a call and use them to re-evaluate his practices and make himself a better provider. NOt saying he's already not a great provider but this can be a way to turn around and be better. From adversity comes strength I believe I heard said one day.

But if his revocation is overturned, might he say "I got away with it once, I can do it again" and do something not so bright again?

[scratrat]

@systemet

Sorry for the blue but I was trying to show my responses to each.

Well, regardless of his intentions and whether the practitioner "saw it once on TV" or was properly trained, State guidelines say "no". End of story. I guess it's a good thing I'm not serving on that board. I don't need to know anymore information as to why he thought it was warranted, what the outcome was, or other mitigating factors. The only mitigating factor I need is a doctor repeatedly instructed you not to perform a skill that is outside your scope of practice in a certain state, and you did it anyway. Period.

A few paragraphs back I read one about paramedics doing a c-section. I had heard of one of those in NJ and I was fairly cetain their certifications were revoked but I may be wrong. The doctor accepted responsibility. But you still practiced medicine without a license and went outside your scope. If they did NOT in fact lose their licenses, they should have. Including some sanctions for the physician who authorized it as well.

[fab]

We'll probably never get to a conclusion on this. If you say, the law is the law then noone can argue against that. But I guess someday you too may run into a patient where you've got to have the balls to do what's necessary. And you've got to consider that he's still operations manager, they would've at least suspended him if he hadn't been doing a good job before...

Not removing the sister from the scene? In her place, I would've wanted to stay there!

[Just Plain Ruff]

We'll probably never get to a conclusion on this. If you say, the law is the law then noone can argue against that. But I guess someday you too may run into a patient where you've got to have the balls to do what's necessary. And you've got to consider that he's still operations manager, they would've at least suspended him if he hadn't been doing a good job before...

Not removing the sister from the scene? In her place, I would've wanted to stay there!

Fab I agree with you to a point but there is no patient where my livelihood is worth giving it up for.

YOu say that you have to have the balls to do what's necessary but that patient in the end is not going to help me pay my mortgage, keep my kids fed and do what I need to do to survive.

I'll do what in necessary for the patient but you paint with a broad brush. Have you been in a situation where you put your livelihood on the line for the patient, all the while knowing that you might not have a job coming the next day?

I'm not going to do that for any patient. This is an extreme case and I'm sure there are other cases not so extreme but when it comes to feeding my family and keeping a roof over my head, I'll choose family any day.

You can bet that the ambulance service you work for isn't going to cover for your ballsy move if it affects them negatively. You can bet that thehospital isn't going to come out and help you out for making that Ballsy move

I can also say that that patient aint about to come and help you out after the fact, after you've lost your livelihood and your house and can't feed your kids, I can bet my next paycheck (it comes this friday and is pretty big) that the patient in question where you "had the balls to do what had to be done" is not about to come help me out after the fact.

So I may be in the minority here but if doing something for a patient will ultimately affect my ability to provide for my family, and I know that I could feasibly lose that ability to provide for my family, well too bad so sad, I'm sorry but that patient will have to wait till I get to the hospital.

I worked too damn hard to get where I am and I'm not going to knowingly(emphasis on knowingly) put myself in jeopardy like that medic did.

Tell me, have you followed your own advice and had the balls to have to do what's necessary no matter what the cost???? Because that is what you are telling us here to do. That we should have the balls to do whatever is necessary no matter the cost. To be totally blunt and to the point - that is a bunch of horseshit.

[DFIB]

I think the state did the right thing. I feel compassion for the offending medic (what a horrible experience and aftermath) but not much mercy. He knew what he was doing, was aware of the consecuences, rolled the dice, a human being died, and he is left to pay the piper. It stinks but, what other conclusion could he have possibly expected.

In Mexico EMT-Bs are allowed training in advanced airway skills that are way outside their scope of practice. If one of our EMTs tries to run an ETT they are gone. Their training is irrelevant.

All off us should know procedures that are outside our scope. We also refrain from using them because we are bound by rules.

In some instances life is really simple.

[Arctickat]

A convicted murderer can be released from prison after serving his sentence and is considered rehabilitated (in most states). If he can get a second chance in society then why shouldn't this medic? Suspend him, retrain him, educate him, just because it was beyond his scope should not be a "death sentence". Even Scratrat admits to "bending the rules". If functioning beyond one's scope is a loss of licence event, then Vermont would likely lose most of its medics. This was a blatant and extreme case with plenty of witnesses, but according to some, beyond the scope is beyond the scope and the punishment should be the same...so if you give 15mg of morphine to a 300lb guy in pain when your protocols state your maximum allowed cumulative dose is 10mg, you'd better be prepared to lose your cert and never work EMS again.

I'll bet there was a second half to what the medic said. "I'm probably going to lose my licence for this," "but the love I have for my friend and her family trumps that."

Like a mentioned in my first post. For such a heavy handed reaction from the state he must have been disciplined before.

[DFIB]

That we should have the balls to do whatever is necessary no matter the cost. To be totally blunt and to the point - that is a bunch of horseshit.

Anyone can have the balls to freelance, the question is, do we have the brains not to.

I have transported patients with medications drawn that I know I am not authorized to give, praying to God that I don't have to. Until now I never have. A lot of our job is about calculated restraint.