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In regards to EMS intubation issues

Mike MacKinnon mmackinnon at cox.net
Tue Apr 11 18:25:06 BST 2006


Hey Ben 
 
I did a little research about this issue in regards to my state. It is
pretty clear that if a paramedic runs into a physician on a scene who gives
an "order" the only way to reverse, ignore or modify that order it to
contact medical control and have the two physicians speak. In this case
(based on the articles presentation) it dosent appear that the Urgent care
physician gave an order but more like a suggestion. Since we dont know how
the actual exchange went, its very hard to tell.
 
Mike M
-------Original Message-------
 
From: Ben Reynolds
Date: 04/11/06 10:18:16
To: Trauma &, Critical Care mailing list
Subject: RE: In regards to EMS intubation issues
 
He may not be able to order the paramedics to intubate
(or do anything for that matter) but he certainly
could have taken medical custody of her from the
paramedics if he saw it fit.
 
In most states, once a physician (no matter what
flavor, whether emergency physician, dermatologist,
psychiatrist, whatever) prescribes a course of care
they are legally and ethically bound to see it to it's
finality until they are relieved by another physician.
  This requirement is not satisfied until the receiving
physician has PHYSICALLY encountered the patient at
his or her facility.  These are the tenets on which
laws governing interhospital transfers (EMTALA) have
been based.
 
The same holds true for people needing medical
attention outside of the hospital or on the street.  A
physician is held to a higher standard of care than
the average good samaritan; a common reason why civil
suits against "good samaritan" physicians or nurses go
forward with such success.
 
Calling an ambulance to the physician's office or to
an urgent care center and handing over a patient whose
condition has unexpectedly changed to a paramedic
doesn't absolve the transferring physician of medical
responsibility if the patient's condition worsens
enroute, even if the argument that it was the "right
thing to do" holds true.  Conversely, the medical
control physician approving a course of treatment for
the paramedics on the patient being transferred does
not make the receiving physician liable because the
"physical contact" requirement hasn't been satisfied.
 
This urgent care physician in this case was obviously
pretty savvy:
 
1.  He did not take the patient into his facility to
examine her and initiate a plan of care on her, thus
it is debatable whether the patient was ever really
"under his care".
 
2.  He only "offered" his assistance to the
paramedics, which was refused without physically
intervening himself.
 
Thus the paramedics are up a creek without a paddle.
If the facts of this particular case had been the same
with different circumstances (ie patient with same
problem but WASN'T picked up out the parking lot of an
urgent care center and a physician HADN'T been
involved) the outcome would probably have been
different.
 
Ben Reynolds, PA-C
Pittsburgh, PA
 
 
 
 
 
--- Robert Smith <rfsmithmd at comcast.net> wrote:
 
> Great points. I'm confused about several of the
> facts as stated also. For
> one thing I'm acquainted with Frank and have always
> considered him a strong
> EMS advocate. Not only do I have doubts about the
> Urgent Care doc being set
> up to intubate, he certainly couldn't "give orders"
> to the medics as he is
> not part of their medical control.
>
> Rob Smith, MD
>
> -----Original Message-----
> From: trauma-list-bounces at trauma.org
> [mailto:trauma-list-bounces at trauma.org]
> On Behalf Of Jeffrey Leach
> Sent: Tuesday, April 11, 2006 8:05 AM
> To: trauma-list at trauma.org
> Subject: In regards to EMS intubation issues
>
> According to the JEMS article, Etomidate is
> described as a paralytic, when
> in fact it is an induction agent. While etomidate
> would be appropriate to
> administer in this case, it may or may not relax the
> Pt. enough to
> accomplish intubation. A true paralytic would have
> solved the problem of a "
> clinched jaw ". If the Paramedics in this case did
> not have a paralytic per
> protocol, one must wonder if the Urgent Care
> Facility Physician could have
> facilitated intubation with a paralytic drug. In
> regards to the
> documentation issue, we should all remember that if
> it is not documented,
> then it was not done...
>
>                   Jeffrey P. Leach, EMT-P
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