Medical Staff for Encampments

[PHall]

Hey, never claimed to be a Latin expert. But you got the idea, so I count that as a success.

[Major Lord]

Phil,

I agree that we stand in loco parentis. Ned is a legal big dog, so I would not challenge him on this  ( although there have been several cases in which lawyers were demonstrated to be wrong)

Having Loco Parentis status means that we have the rights and obligations of the little badgers' parents. Now we create a regulation that says "we, as stand-in parents, have decided not to provide routine medical care within the scope of practice of any parent, for fear of being sued, after assuming responsibility for your children". The harm to the child is foreseeable, since we have agreed not to meet a standard of care which is inferred by our standing.

Further, we ask the parents to provide a medical waiver (form 31) and Hx questionnaire that implies that we will interpret and act upon any special health problems the cadet may have. We know in advance that no such service will be provided, and in fact may also be proscribed by regulations.

As an organization, we have either denied we stand in loco parentis, or we imposed a limitation on a doctrine of the common law by  CAP regulation. Both of these are legal assertions of questionable validity.

I don't see how the regulations provide any exemptions for blister treatment. I suppose you could argue that an assessment is not a treatment, but to say that either case is not "routine medical care" is specious.

Major Lord

[PHall]

I don't see how the regulations provide any exemptions for blister treatment. I suppose you could argue that an assessment is not a treatment, but to say that either case is not "routine medical care" is specious.

Major Lord

What blister treatment? Cadet shows us their feet after they have showered and answer a few questions. (How are the feet? Do you have any blisters? etc...)

If they have a blister or just an red area we give them a band aid or some moleskin and send them on their way.
And I mean just that, we give them the band aid and/or moleskin, they apply it themselves.
Homie don't touch no nasty feet!

Like I said before, anything that can't be handled by a band aid or some moleskin gets shipped off to the Doc-in-a box.

[Major Lord]

Phil,

So you knowingly and willfully provide a medical assessment of the cadet, and provide direction and materials for treatment? This sounds like "routine medical care" to me. ( The black IG van is pulling up in front of your house now...)

Believe me, I am not arguing that we should not care for our injured cadets (officially, I take no position on this, but as an EMT, you might guess my feelings)

What I am arguing is that the regulations are so over-broad, as to prohibit routine and common sense parental-standard practices. If the letter of the law was followed, encampments would not be possible. When we determine that for instance, a Cadet's chest pain is caused by running for a mile, rather than say, pneumonaultramicroscopicsiliovolcaniosis, are we not making a medical evaluation that any parent, or reasonable person, might make?

The regulations have been drafted in such a manner as to replace common sense and moral and legal duties. Its not the practice of Moleskinning that is wrong, its the regulations that prohibit it. I don't think that there is any question that CAP reg's flatly prohibit any routine medical aid, including cold packs, hot packs, or providing any over-the-counter medical aids, to include chapstick, Tylenol, sunscreen, ace bandages, bandaids, moleskin, vaporub, etc. You can argue that it is common sense and common practice  to do these things, but the practice is by CAP standards, illicit.

We need to make it clear to parents that when it comes to the health of their children, we assume no responsibility.( at least by choice)

Eventually, CAP will be sued by a parent or member, when we breech our duty of care to our "yoots" and National will revisit drafting such over-broad and ill advised regulations. If we have any money left to run the organization, at least all of us medical people can have "I told you so" rights. Small consolation.

Major Lord

[RiverAux]

What about providing water to prevent dehydration?  Requiring cadets to wear jackets to prevent hypothermia?  Could this be medical advice or treatment in the hands of some lawyers? 

Anyway, I agree with Maj Lord and others that our medical regulations are very messed up and CAP has seemingly done everything it can to confuse people.

[John Bryan]

It's about MONEY.....and the risk of lossing  it.

CAP Medical / HS personnel who want to take care of people should join the USCG Aux and be protected by the federal government. CAP is a private corp and needs to be careful.

I also think we should follow the regs to the letter. Send cadets to the hospital for blisters and every other little thing. The cost will maybe make CAP and the AF reconsider how we do business.

Don't collect meds at encampments...let the cadets keep them. When the ADD meds go missing and a cadet OD's then we will get sued and maybe the regs will be reviewed. Show me one summer camp in America that lets 12 and 13 yrs keep their meds in the cabin.

CAP is at risk for being sued no matter how you look at it.....but CAP members need to follow the rules and let the chips fall.

[Ned]

What about providing water to prevent dehydration?  Requiring cadets to wear jackets to prevent hypothermia?  Could this be medical advice or treatment in the hands of some lawyers? 

Guys,

Quit trying to think too hard.

You will hurt yourselves.   



Lawyers are not the enemy here.  No one has ever been sued for giving water to a CAP cadet or handing them a jacket when it is cold outside.

Because nobody outside a law school bull session or a internet bulletin board would ever remotely think that those things are "medical care," routine or otherwise.

While I agree that we could make the 160-1 a little clearer and provide some affirmative guidance to CP leaders, it isn't really all that mysterious.

Lay folks (as in people who don't hold a medical license of some sort) can do lay-people stuff without fear of lawsuits.  Hence TACs can pass out band-aids, sunscreen, and ask questions like "why are you limping, cadet?"

Mostly because Moms and Dads are not "practicing medicine without a license" when they care for their children in similar ways.

But lay people -- including Moms and Dads -- can't do stuff that requires a medical license; like surgery and diagnosing serious illnesses.

And by regulation in CAP, medical folks can't do routine care for the reasons we have discussed.

But TACs and other adult officers who who care for cadets can certainly use common sense and experience to pass out the moleskin and bandaids.

Remember, food is the number one cure for "hunger," a serious condition that can be fatal without intervention.

But thank Goodness you don't have to be a physician to run the dining hall.



Peace and common sense to all.


(BTW, a NHQ HSO committee is nearing the final stages of a revision to 160-1 that will address the medication and other issues.  The state laws vary tremendously across this great country, and it is very difficult to craft a policy that will be acceptable in all 50 states and various commonwealths and districts where CAP has overnight cadet activities.  But the good news is that we have a very good track record in caring for our cadets.)

[John Bryan]

Ned is correct Lawyers (well some lawyers) are not the enemy.  We have a great legal team at NHQ.....If I recall correctly the National Legal Officer's practice outside CAP is to defend doctors and medical people who are being sued. So the knowledge is there.

The problem is not the lawyer but the law and CAP regs. As long as we are Civil Air Patrol, INC and not the US Air Force Auxiliary we will have a lot of these problems. We have a lot of health care people who want to help hurting people from plane crash victims to cadets with blisters and a lot in between. The problem is they have there hands tied by our regs which are based in law suit prevention. If our status changed our medical folks could do what the USCG Aux medical folks do and that is act as USCG medical. The USCG Aux who are doctors, nurses, and other HSOs can actual work in USCG clinics treating active duty USCG members , retired members, and families. Those state laws and all are covered because they are a federal resource. What that means for example is a nurse who works for the VA in Ohio may have an Indiana license and there is no problem because she/he is a federal nurse who only needs to be licensed in one state.

So how do we change things....well we don't. The CAP and AF leadership would have to go to Congress. When will that happen? When the money (costs) lead them there. For example if we send 50 cadets to the hospital during a summber encampment for routine care and their HMO, PPO, whatever covers everything but $200....now NHQ pays $10,000....times say 40 wing encampments = $400,000.00.....my advice if you want change follow the regs. Right now we have doctors and nurses and medics (sorry) who are doing things like basic care and passing meds and such and CAP gets the best of both worlds, on one hand they are not spending the money on outside hospital care and they can cut loose the HSO if they are ever sued. Why do you think NHQ has never enforced these rules.....why do you think every encampment and other large event collects meds and then passes them. It's nuts......FOLLOW THE REGS. Let the cadets and adult officers go to ER for everything.....let the cadets keep their meds (including strong ones for ADHD). If all 52 wings followed the regs...the cost would lead to change.

[RiverAux]

Well, the CG Aux program may be dying out according to some statements I've heard.  I'm not sure that it really ever got much off the ground in the first place. 

[Ned]

John,

While I think we can all agree that CAP members should have access to quality medical care while attending CAP activities, I believe your "take everyone to the ER" advice is very ill-advised.

First, such activities do not apply any effective pressure to decision makers in CAP, the USAF, or Congress.  CAP, Inc is not liable for the medical costs of members, period.  If my kid goes to a civilian hospital during encampment, I am on the hook for any expenses not covered by my insurance, not CAP.

Second -- and more importantly -- sending anyone to an ER for routine care is wrong, and dangerous.  It is wrong because ERs are for . . . wait for it . . . emergencies.  It is dangerous because ERs are not equipped for routine care and any time they spend looking after non-emergent cases simply leaves less time and resources for true emergencies. 

I also think you may have made some unwarranted assumptions: many, if not most, encampments no longer routinely collect and store medications.  And while there are some scary exceptions, most CAP HSOs (especially the docs and nurses) understand and follow the regulations and do not perform routine care or prescribe medications.

National and regional headquarters (including folks like me) do in fact routinely enforce the regulations everytime we become aware of a problem.  I visit several encampments every year, and I do not see any widespread violations.

(But I hear about some in other regions.)

I agree with you that the only practical solution is some sort of legislative change through Congress, that would somehow give Federal status to our HSOs providing routine care to members and the general public.  This leads to the follow-on problem of educational and licensure standards.  Do we really want to make all of our HSOs meet USAF training and educational standards?  Maybe.

The only alternative is to purchase medical malpractice insurance that covers all of our HSOs as well as CAP, inc.  As we pointed out in the other thread, a conservative estimate would be several hundred thousand dollars a year to cover us in all 52 wings.  Money which, needless to say, we don't have.

It is also worth remembering that we are not exactly in crisis here.  CAP has hundreds of overnight activities every year, including 40 or so encampments.  For routine care, members have full access to the regular health care system:  their private physicians, clinics, and other providers.  In emergencies, CAP does pretty much what everyone else does -- we call 9-1-1 and the members will receive some of the best care in the world.

Would it be more convenient if CAP HSOs could offer routine care?  Absolutely.  I have commanded several encampments with more than 200 folks, and I would dearly loved to have had a doctor or PA to triage the tummy aches, "sprained" knees, and common colds.  I didn't have a CAP doc, so we made do with USAF medics, a non-member "camp nurse," and the local urgent care clinic.  The world did not come to an end, and nobody's health was endangered.

But I again strongly caution against a "send them all to the ER' policy.  It is not required by any regulation, it would not accomplish what you want it to, and it is wasteful of scarce health care resources.


Peace.

Ned lee

[RiverAux]

Several hundred thousand dollars is not much of CAP's budget and the AF wouldn't even notice the cost.  If a reasonable case can be made that our current system is causing actual problems then I think something could be done. 

However, I don't think reasonable people are in charge of CAP at the AF level.  The decisions that have come down lately over what missions they'll allow AFAM status for and which ones they won't have been so inconsistent that trying to predict what they would do about something like this is a sort of crap shoot. 

[Ned]

Several hundred thousand dollars is not much of CAP's budget and the AF wouldn't even notice the cost.  If a reasonable case can be made that our current system is causing actual problems then I think something could be done. 

Sure, we could add $10 to the dues for every senior and probably cover it, but I suspect we might get some push-back from the membership.  Remember, this is the same crew that complains bitterly if we tell them they have to buy a $3.00 uniform item sometime in the next two years.   

But I think you are right that the USAF would take some convincing before they would undertake such a large responsibility.  I can't begin to imagine how they would take responsiblity for the training and certification of such a diverse group of health care providers located in all 50 states and Puerto Rico.  But the larger problem is that they would almost certainly take the position that "if it isn't broken. . .."  From their perspective, we are already managing to ensure our members get routine care, and our HSOs are already permitted to help in genuine emergencies.

[Psicorp]

Just out of curiosity, I understand the liability issue with providing basic medical care, but how can we (CAP) say no to providing care if a Paramedic or Nurse has their own liability insurance?

[Eclipse]

Just out of curiosity, I understand the liability issue with providing basic medical care, but how can we (CAP) say no to providing care if a Paramedic or Nurse has their own liability insurance?

Its easy, just say it.  If a member chooses to take an action against a CAP directive, they would be subject to disciplinary action within the organization and would be forfeiting liability protection.

The "Scylla and Charybdis" here is that many states have laws which require licensed medical, fire, and law enforcement personnel to act and/or administer treatment in emergencies.  That debate is another ad nauseum discussion here.

It has to be made clear to these members, and should be discussed BEFORE its an issue, that in those circumstances they effectively remove their insignia and become agents of whatever agency or profession requires they act, with no implied or actual protection by CAP, or FTCA.

[Ned]

Just out of curiosity, I understand the liability issue with providing basic medical care, but how can we (CAP) say no to providing care if a Paramedic or Nurse has their own liability insurance?

Jamie,

The problem is that while such insurance may well protect the individual, it does not cover CAP, Inc., who would most likely be seen as the "employer" here.

IOW, if it should happen that a CAP HSO were to treat a member, and malpractice occurred, the member would sue not only the individual that committed the error, but also CAP, Inc. on a number of theories, including failure to train and/or supervise the HSO adequately, failure to provide necessary equipment and supplies, and/or simply on an employer-employee relationship.

If that happens, the HSO's insurance may well cover the HSO, but will not cover CAP, Inc.  Any lawyer seeking compensation for her/his client will always go after the "deep pocket" which in this case would the corporation.

And it wouldn't take too many multi-million dollar recoveries to make CAP, Inc simply go away.

As a practical note, even in cases where CAP wins the lawsuit or settles for a nuisance amount, we would incur legal fees amounting to tens of thousands of dollars.

So that is why we have the rule that says CAP members do not provide care in anything other than a genuine life-or-limb threatening emergency.

We could of course purchase medical malpratice insurance to protect the corporation, but that would cost several hundred thousand dollars a year.  Now add to that the legal fees to deal with the lawsuits, and you get some idea of how expensive it would get.

Ned Lee
Former CAP Legal Officer

[Psicorp]

Fair enough, sir, thank you.

I'm going to be starting Nursing School here shortly (mid-life career change), and had been (okay, still am) hoping to help out at Encampment on the medical side in a couple of years.  Maybe things will change by then.  [laughter] [/laughter]

[Jolt]

I remember at COS when Capt Waddel, a paramedic, came in to treat one of my roommates for a cut or something to the knee.  It obviously wasn't life threatening.  It was just oozing a little bit.  The treatment consisted of washing it off and bandaging it cut.

Would that have been considered routine care, Col Lee?  I know none of my roommates had a problem with it.

[Eclipse]

I remember at COS when Capt Waddel, a paramedic, came in to treat one of my roommates for a cut or something to the knee.  It obviously wasn't life threatening.  It was just oozing a little bit.  The treatment consisted of washing it off and bandaging it cut.

Would that have been considered routine care, Col Lee?  I know none of my roommates had a problem with it.

Only an IG,  judge, or jury could say for sure.

Clearly dressing a superficial wound is within both a paramedic's training and the community-level first aid CAP requires, but then it gets gray from there.

As a commander, a parent, and an adult with common  sense, I have a petty good idea what can and cannot fall under the duties of an HSO, however we all know common sense has no specific standing in an American court of law, especially a civil one where the jury thinks the defendant has deep pockets.

Trying to narrow it down here is going to be like trying to wrestle a greasy pig - you can get a pretty good grip on it, and then when you're not looking it'll get away from you.

The only thing any of us can do is our best within our own personal risk tolerance and skill set.

And then cross your fingers.

[capchiro]

An interesting case for discussion.  At a recent weeklong encampment, a cadet approached the chaplain and stated he wanted to go home.  the Chaplain, told the cadet he would be okay and to hang tough.  The cadet said he was depressed and began to cry.  The Chaplain told the youth that this was a common problem he had seen before and that the cadet was just feeling down due caffeine withdrawal.  He gave the cadet a waiver so the cadet could have a Coke at lunch each day (since all sodas were off limits).  The cadet did so and completed the training.  A success??  Perhaps.  Now the problems.  Was this a medical condition?  Could it have been a medical condition.  Could the cadet have been suffering from depression and committed suicide?  Was the Chaplain qualified to "diagnosis" any kind of nutritional or drug withdrawal??  Would a HSO been qualified to do so??  I think the Chaplain was very creative and it would appear that he did a good thing, but if it had gone wrong, it would have been a very bad thing to say the least.  What do you all think of this situation.  It really happened..

[Ned]

Guys,

Again I caution all of us about thinking too hard.

It doesn't take a licensed physician and surgeon to wash and bandage a scraped knee.

Mom does that every day, and nobody is threatening to arrest her for practicing medicine without a license.

Now if it is obviously infected, we have clearly gone beyond the "soap, water, and band aid" stage and it should be seen by a professional.

I'm pretty sure that any reasonable adult would see the difference and act accordingly.

Sure, there is always going to be some grey when we try to figure out exactly where the line is (what if it's a only a little red? ; what if it is so painful the cadet can't walk without limping?, etc.), but that is why we hire only hire adults with a little common sense to supervise troops.



As for the chaplain "diagnosing" depression, we are back at the same question.  If the kid is a feeling a little anxious over her/his new surroundings or perhaps homesick because this is the first night Junior has spend away from home, any sensible senior (including chaplains  ) will listen to the troop for a bit, reassure them that these are normal feelings for someone in their situation, and send them back to duty.

Heck, maybe even give the cadet a cookie.

But if the kid comes in saying things like "i've been diagnosed with clinical depression by my shrink, and my meds aren't working in this environment.  I am withdrawn, tearful, and feel like hurting myself or others" well, then the Chaplain is out of her/depth and needs to refer the kid to a professional.

And if you're not sure, ask another responsible adult.

Really, we have had thousands of encampments that have graduated several hundred thousands cadets without getting vapor-locked over whether telling a cadet to put moleskin on a blister is medical treatment that must be performed in a ER.

Nobody in CAP has ever paid a nickel in damages for acting responsibly, respecting and caring for cadets as we would our own kids, or applying common sense and experience to CP situations.

That's all we need to do.