Saturday, December 12, 2009

Complacency Kills…Patients and Careers

I did my paramedic internship at Los Angeles City, Rescue 66, in the spring of 1989. You might think I am crazy, but I recall that as being one of the best times of my life. My preceptors, Mike Samudio and Kelly McKee were clinically tough, but very fair. They did what they had to do to make sure that I could do what I had to do when I had to do it.

What I remember, and appreciate, the most is that they took the time and spent the energy to make sure that I always considered and appreciated the role of a paramedic from the patient’s perspective. With them, even the twentieth patient in as many hours received the attention, respect, and care as the first. The sweet old lady with chest pain, the juiced-up gang-banger with a gunshot wound, and the homeless drunk with a bellyache since 1964 were all treated with the same attention to proper care (as patients) and proper treatment (as human beings).

As it is with many interns, about half way though my internship I became too comfortable with my preceptors and my skills. I recall one particular incident like it was yesterday. It was the middle of the night; I was tired and cranky and faced with (another) young woman who was emotionally upset over something her boyfriend had done. She was in no distress and the very thorough assessment – including an EKG – revealed nothing more than big trouble for boyfriend when he returned. Nevertheless, with the Captain, Engine Company, family members, and preceptors watching, I presented her with disposition options: First, I told her, we could take her to the hospital if she desired. Or, I continued, she could stay home with her family and see her private doctor in the morning. Had I stopped at those two options, there would be nothing about which to write. Of course, I did not. Her third choice, I presented smugly, was “…or we could take you to Disneyland. That always makes me feel better…”

I could see the words as they left my mouth and hit the air. They would not be retrieved. The damage was done. The simultaneous and confounded looks of disappointment on my preceptor’s faces said it all. I am reasonably sure that, if I had a tail, it would have instantly lowered and tucked itself between my legs.

When the dust settled, and there was a lot of dust, Kelly McKee pulled me aside and calmly gave me some of the best advice I have ever received: “Dave,” he said, “your not going to like everyone you come in contact with. Sometimes you’re going to be tired and sometimes you may not want to be there. But, as long as you are, remember this: Complacency Kills. The minute you begin to treat people differently or cut corners, someone is going to die…and it could be you.”

I have never forgotten that lesson. I have passed that wisdom on to every intern I ever precepted and tried to apply it in my daily life. Now, I pass it on to you.

I shared my story, albeit rife with sentimentality, to provide a bridge from conceptuality to tangibility; to encourage some reflection on your own career as we analyze a case where complacency did kill.

Wright v City of Los Angeles
On May 19, 1979, witnesses saw a fat man picking up Jerry Wright and hitting him up against the side of a car as Wright screamed, “Help, police, I'm being robbed.” Wright tried to get into the car, but the other man pulled him away and continued to beat him. Moments later, a man came out of an apartment across the street and hit the fat man, who fell under the car. The man then helped Wright into the car. When he started it up, it rolled backwards, and then stopped; Wright just sat there.

Moments later, two police officers arrived; one had his gun drawn and pointed at Wright and ordered him to come out of the car, but he did not comply. He remained slouched and leaning against the back of the driver's seat. Another witness urged the police not to shoot, saying that Wright could not get out of the car because he was beaten up or hurt, and that the man on the ground had done it. The officers opened the passenger door and pulled him out, half into the gutter. One of the officers poked him with a baton, but he did not move. The other officer pushed him over onto his stomach, put his hands behind him and handcuffed him. He was lying on a grass parkway, with his head leaning over the sidewalk; one of the officers kicked him between his neck and shoulders and moved his head back onto the grass.

Witnesses heard Wright loudly complaining that his head hurt, that he hurt all over and needed an ambulance. The police called for paramedics. Soon after, an ambulance with two paramedics arrived to find numerous police vehicles and officers, and the fat man lying in the street. A police officer directed one paramedic to Wright; the other attended the fat man. The paramedic did not recall being told Wright had been complaining of pain or that he hurt all over and had asked for an ambulance. He knew that there had been a fight and assumed that was why the paramedics had been called, he never asked the police why they had been called.

The paramedic approached Wright and asked him what was wrong or what had happened; Wright did not respond. He asked Wright if he was hurt and Wright said he was not hurt; he did not complain that he hurt all over. The paramedic did not ask Jerry a series of orientation questions. While the paramedic was talking to Wright, he was examining him visually to determine why they had been called to the scene. He then did what he called “…the 60-second examination…” a brief visual examination of the body to determine if there is a life-threatening situation. It was the only examination he did; he did not check a pulse or blood pressure. He did not recall if he touched Wright’s skin, although he could have done so while examining his body for visible injuries. After the 60-second examination, he told a police officer if Wright was to be booked he should probably see a doctor first; the paramedics then left.

Wright died at the scene a short time later from Sickle Cell Crisis. The paramedic was found liable and the plaintiffs were awarded millions.

Wright v. City of Los Angeles has become a landmark case for EMS providers everywhere the duty to act is at issue. Recall from my column “Are You Just Down the Street From a Lawsuit,” the Zepeda case established that staging away from certain non-secured situations did not violate the provider’s duty to act, particularly because the paramedics never initiated patient contact before the police arrived. In Wright, however, the scene was secure and the paramedic initiated patient care by approaching, asking questions, and making a substantive disposition.

When it comes to a provider’s duty to act, most every jurisdiction follows the same essential rules: The provider has a duty to act as would a reasonable provider with the same level of training and skill, in the same locality, and under the same or similar circumstances. Acting reasonably is not rocket science, yet so many providers continue to stumble around the standard, guided by what they think they know rather than what they actually know.

One of the first questions for the jury was: did the paramedic have a duty to act? Of course he did. He was summoned to the scene of an emergency to perform the duties for which he was hired; to empirically determine the patient’s condition through the use of available diagnostic tools and assessment skills. Likewise, he had a duty not to rely solely on the statements or non-statements of others, including the patient himself.

In this instance, a “reasonable” paramedic would have asked more about the circumstances which led to the response. A “reasonable” paramedic would have been motivated by the story of a fight to do a physical assessment including vital signs. A “reasonable” paramedic would have wanted to know about medical history because that is what reasonable paramedics do; like lawyers, they gather as much information as possible to get to the truth, or to at least reach an informed conclusion. A “reasonable” paramedic knows that what you see is not always what you get.

The next question for the jury was: did the paramedic breach the duty? Where one owes a duty and fails to perform, he is in breach. This was not a stretch for the jury and it will not be a stretch for you either. Chances are, unless you are absolutely clueless, you already know as you walk away from a call whether you did everything you should have – according to local training, protocols, procedures, and standards of care, not according to your psychic abilities and unquestionable experience. If you didn’t, then the possibility that you missed something, as infinitesimal as it may seem, will follow you wherever you go… at least until the statute of limitations runs out.

The last questions for the jury included: were there damages and did the paramedic’s breach of his duty cause them?

Determination of cause essentially boils down to two words: “But for…” But for the paramedic failing to do the full and complete assessment which was his duty, would Mr. Wright have died as, how, and when he did? The truth is there is no way of knowing.

On the other hand, we do know that if the paramedic had done a full and complete assessment and learned of the sickle cell disease and transported the patient to the hospital, rather than passively suggesting to the police that a doctor look at him if he is to be booked, Mr. Wright would have received advanced medical attention and his odds of survival would have improved exponentially over what he received face down in the grass.

All too often paramedics develop preconceived notions and even generate conclusions before they arrive on the scene. Sometimes that works. If you know you are going to the scene of a vehicle roll-over, it is safe to assume that a trauma center is a probable destination. Or if you are called to the scene of an overdose, person not breathing, you may reasonably forecast the use of Narcan®. Experience tells you certain things.

However, a drunk is not always a drunk. Each patient and every situation is unique, even those you have seen a thousand times. And you will never know until you have done a comprehensive and thorough assessment. Would you do a 12 lead EKG on a 34 year-old female with abdominal pain? I recall an afternoon when my partner and I did, mostly because we could. Wouldn’t you know it? She was having an MI.

As long as I live I will never understand how some providers continue to find a disadvantage to doing a full and complete assessment; how, as a matter of course, they rationalize circumstances where it’s just to burdensome to check vital signs and ask all of the necessary and appropriate questions. Perhaps it was my training, or maybe it’s just me. But it will never make sense.

Next time you find yourself on scene with “nothing,” I suggest you prove it. Because, when you will need me.

Wright v. City of Los Angeles: 219 Cal.App.3d 318, 268 Cal.Rptr. 309 Cal.App. 2 Dist.,1990.
Zepeda v. City of Los Angeles: 223 Cal.App.3d 232, 272 Cal.Rptr. 635 Cal.App. 2 Dist.,1990.
Torts-Cases and Materials: Prosser, Wade and Schwartz, 10th (2000)

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