Medical Staff for Encampments

[Slim]

Ned,

As usual, your words are very wise, and your experience and knowledge are worth listening to.  As someone who will be commanding his first encampment starting in 262 days, this is one of the many thoughts in my mind.

Our encampment does maintain a medical section.  It is typically staffed by 3-4 senior members who are EMTs and Paramedics at a minimum (we occaisionally have had an RN or doctor thrown in).  We certainly don't allow cadets with stethoscopes and 40 pound truama bags (nothing against cadets, stethoscopes or trauma bags, but cadets should be doing other things during encampment).  These guys and gals don't do anything more than what a TAC (or any reasonable person) would do when it comes to treatment.  If you would be so kind as to look at some scenarios and offer up an honest opinion.

• TAC notices a blister that's an angry red color and still draining fluid.  Thinking infection, he takes the cadet to the medic.  The medic says "Yeah, could be.  Let me put some Neosporin and a fresh dressing on it.  Keep an eye on it and let me know if it doesn't get any better."
  
• Cadet strikes his head on a low roof overhang, causing a deep laceration/avulsion.  Medic slaps some 4x4s on it, loads the cadet in the van with a driver, and goes downtown for some stitches/staples.
• After eating dinner, a cadet starts complaining about her throat feeling fuzzy, and some shortness of breath, so her flight sergeant takes her to medical.  The medic on duty, recognizing an allergic reaction, has HQ make a 911 call for an ambulance (about a 20 minute response time).  Meanwhile, the cadet says her throat feels like it's starting to close up, and she's having a hard time breathing.  So, the medic asks for her drug allergies, and having no contraindications, gives her some of his personal Benadryl.  Ten minutes later, when the ambulance arrived, the cadet was breathing fine, and having no other difficulties.  She still went downtown in the ambulance for an evaluation. (Later, we found out the cadet had a seafood allergy.  While we had been served chicken, the group before us had fish and the dining hall staff neglected to change the serving utensils.)  I will stipulate that this may have been pushing it, but I also know how fast anaphylactic shock can set in and be fatal.  Once that throat closes, the only way to get an airway is by tracheotomy or crichoidotomy.
• Cadet rolls his ankle on the O course.  Medics come along splint it to prevent any further injury, maybe put an ice pack on it to reduce swelling, and take the cadet downtown for some new photos.

In my mind's eye, I don't see these as being anything less than what the average parent would do in these situations (well, ok, not really, but don't get me started on abuse of the EMS system).  I also don't see any of these as being beyond basic, common sense first aid, or in the one (admittedly rare) case, lifesaving treatment, both of which I interpret as kosher by the 160-1.  And, nothing that can't be done by any senior at encampment.  We just prefer to recruit and use licensed professionals because they have the ability to recognize what they're seeing, and more importantly, what they can't see.

Short of bubblewrap BDUs, or calling an ambulance for every little thing, how can I ensure the safety of the cadets entrusted to ME, while protecting the corporation (and myself) from liability, and taking care of all those minor scrapes, bumps, cuts and bruises inherent to any encampment?  Do the provisions of 160-1 become moot just because a paramedic is the one to put the band-aid on?

I'm not trying to pick a fight here or anything, this is just one of those areas that I'm thinking about as a commander.

[Eclipse]

You didn't ask me, but what the heck...

This has been my worst nightmare for about 6 years, now.

Everything you said was reasonable and fine up to the giving personal Benedryl - you lost me there when you moved into allowing the HSO to make a diagnosis and then dispense a medication.

IMHO, at the point someone makes a diagnosis, they lose their insignia and corporate backing and must fall back on their professional insurance and requirements.

I wouldn't give anything, ANYTHING that is remotely medication to a cadet without express permission of that cadet's parent or legal guardian.  If a senior wants to self-medicate out of my kit, well, that's their choice.  A minor isn't legally allowed to make that choice.

The worst, most painful part of this whole situation is our volunteer status - as has been pointed out, no one can cite a case where a CAP member was sued successfully for making a best effort and common sense, but I certainly don't want to be the first, either.

Nice choice - let someone possibly die or sustain permanent injury instead of risking your own familiy's financial health.

And when you ask NHQ for real, specific guidelines, they point at the regs as if that's an answer.
And those paramedic wanna bes with "advanced first aid" and a stethoscope don't make it any easier for us, because everyone, including NHQ, knows that if and when the regs are relaxed, there will be stretching and abuse of the system - there already is today - you hear all the time about cadets who are candidates for ICU who get two salt tabs, a glass of water and sent back to their racks (instead of going to the ER or home).

Let our people start doing "real" EMT work and you'll have the rambo types giving each other field sutures
and splinting breaks.

[Jolt]

You didn't ask me, but what the heck...

This has been my worst nightmare for about 6 years, now.

Everything you said was reasonable and fine up to the giving personal Benedryl - you lost me there when you moved into allowing the HSO to make a diagnoses and then dispense a medication.

IMHO, at the point someone makes a diagnoses, they lose their insignia and corporate backing and must fall back on their professional insurance and requirements.

I wouldn't give anything, ANYTHING that is remotely medication to a cadet without express permission of that cadet's parent or legal guardian.  If a senior wants to self-medicate out of my kit, well, that's their choice.  A minor isn't legally allowed to make that choice.

Wow... How is an airway compromise not a real emergency?  You really don't need to be a heathcare provider to realize that you can't live if you can't breathe.

How about a new rule that would apply to this situation: "Save lives first, ask questions later."

[Eclipse]

You didn't ask me, but what the heck...

This has been my worst nightmare for about 6 years, now.

Everything you said was reasonable and fine up to the giving personal Benedryl - you lost me there when you moved into allowing the HSO to make a diagnoses and then dispense a medication.

IMHO, at the point someone makes a diagnoses, they lose their insignia and corporate backing and must fall back on their professional insurance and requirements.

I wouldn't give anything, ANYTHING that is remotely medication to a cadet without express permission of that cadet's parent or legal guardian.  If a senior wants to self-medicate out of my kit, well, that's their choice.  A minor isn't legally allowed to make that choice.

Wow... How is an airway compromise not a real emergency?  You really don't need to be a heathcare provider to realize that you can't live if you can't breathe.

How about a new rule that would apply to this situation: "Save lives first, ask questions later."

Of course an airway restriction or blockage is an emergency. however the scenario has EMS on the way.

If the cadet lives, you get a Comm Comm or better, if she dies, you may lose everything.

Professionals are >paid<, protected, and authorized to perform these functions, possibly even duty-bound.
Volunteers are not (at least not as-such).

The problem with this whole conversation, which is going to the same place they all do is that the question really is:

"What >would< I do?'  or "What >should< I do?"

The ultimate answer is impossible without a lawyer, two corporate officers, and specific details of the exact scenario.

My answer on a military installation in an urban area with EMS 3 minutes away may not be the same as someone on a wilderness mission in the California mountains.

[Ned]

Chris,

See that's the thing.

It's an legitimate question:  "If a TAC can do it, why can't a medic do exactly the same thing?"

And the answer is because the TAC is acting as a lay-person, doing the TAC thing, but medical professionals can never act as lay people -- they are licensed professionals that are held to higher standard.

Think about it.  The whole point of a negligence/malpractice suit is that the doc failed to meet the "standard of care" of folks with her/his license.  While a lay person is simply held to the standard of an ordinary guy on the street.  If a doc could avoid liability by saying "hey, I wasn't acting as a doc when I sutured that wound, I was acting as a layperson and successful Home Ec grad," then there wouldn't be much left of the whole malpractice thing.

So the law holds medical professionals to the standard of medical professionals, even when doing stuff that a layperson could do.

To tie this back to your hypos, if a TAC could do it, then a TAC should do it.  If it sounds like the TAC couldn't handle it, so we bumped it up to the medical professionals, then that's probably what happened and the dreaded "routine medical care" probably occurred, even if all that happend was that the medic washed it and put on moleskin.

Part of being a medical professional is the skill in diagnosis that tells you when NOT to do something, so the fact that they chose not to do something doesn't mean that they did not act as medical professionals.

I am not a CAP commander and most decidedly do not make policy, but having a medical section staffed by licensed professionals that puts hands on patients for anything other than a true emergency endangers the corporation.

Period.

As a practical matter, most TACS can tell if a problem is something that can be dealt with with moleskin and band aids, or if we need to call 9-1-1.  For all the stuff in the middle ("twisted ankles", abdominal pain, high fevers, etc. should be seen by some sort of (non-CAP) professional.  These days, the most accessible folks like that are typically the urgent care clinics (aka Doc in the Box).  It's not that big a deal to have the TAC talk with Mom, and then get the kid transported to the clinic where they are usually seen in less than an hour.  The kid's insurance pays (Mom gives a credit card over the phone for any co-pays), and everybody's happy.

The biggest drag is the loss of an adult who escorts the troop to the clinic and waits around.

That's what I use chaplains for.   

[Eclipse]

To tie this back to your hypos, if a TAC could do it, then a TAC should do it.  If it sounds like the TAC couldn't handle it, so we bumped it up to the medical professionals, then that's probably what happened and the dreaded "routine medical care" probably occurred, even if all that happened was that the medic washed it and put on moleskin.

Part of being a medical professional is the skill in diagnosis that tells you when NOT to do something, so the fact that they chose not to do something doesn't mean that they did not act as medical professionals.

The above is likely going to be quoted in my next encampment's senior training.

Well put.

[Slim]

Chris,

See that's the thing.

It's an legitimate question:  "If a TAC can do it, why can't a medic do exactly the same thing?"

And the answer is because the TAC is acting as a lay-person, doing the TAC thing, but medical professionals can never act as lay people -- they are licensed professionals that are held to higher standard.

And I agree with you.  I'm not trying to start an argument or even a lively discussion.  Ok, so the standard, layman's practice for a blister is to wash it out, put moleskin and a band aid on it, then drive on.  Guess what?  The standard for an EMT/medic is the same.  These guys aren't doing anything any different than what anyone else would do. 

To purposefully throw a wrench in the gears, what if you had a TAC officer who was also a paramedic?  Does that same, "Reasonable person" rule apply?  Or, do you send the cadet to the next flight over after telling him "Sorry, I can't put a band aid on you because I'm a paramedic.  Go next door and see Lt Jones, he can hook you up."

Think about it.  The whole point of a negligence/malpractice suit is that the doc failed to meet the "standard of care" of folks with her/his license.  While a lay person is simply held to the standard of an ordinary guy on the street.  If a doc could avoid liability by saying "hey, I wasn't acting as a doc when I sutured that wound, I was acting as a layperson and successful Home Ec grad," then there wouldn't be much left of the whole malpractice thing.

Again, I'm not questioning that.  What I'm questioning is that-under Michigan Compiled Laws-I'm like a police officer.  I'm an EMT regardless of whether my employer is paying me or not.  I have a duty to act all the time.  As long as the accepted standard of care is followed, I'm safe.  We're not giving physicals, stitching wounds, or prescribing medications.  We're doing what is acceptable to a reasonable person to minimize pain and suffering until definitive treatment can be obtained.

So the law holds medical professionals to the standard of medical professionals, even when doing stuff that a layperson could do.

Even when that standard is the same?  Regardless of whether I'm a TAC who took basic first aid 15 years ago, or someone who works in the field every day?  ARC teaches us that the proper thing to do if you suspect a fractured limb is to splint it as it lies and activate 911, or take the person to ER.  EMT school taught me that the thing to do if I suspect a fracured limb is to splint it as it lies and take the person to ER.

To tie this back to your hypos, if a TAC could do it, then a TAC should do it.  If it sounds like the TAC couldn't handle it, so we bumped it up to the medical professionals, then that's probably what happened and the dreaded "routine medical care" probably occurred, even if all that happend was that the medic washed it and put on moleskin.

Again, I think where we're faltering here is what defines routine medical care.  Does putting a band aid on a blister constitute routine medical care, or is it basic first aid?  To me, if it's routine medical care, it shouldn't be done by anyone in CAP; whether that person has an ARC Responding to Emergency card, or is the top neurosurgeon in the country.  Routine is routine. 

Part of being a medical professional is the skill in diagnosis that tells you when NOT to do something, so the fact that they chose not to do something doesn't mean that they did not act as medical professionals.

Unfortunately, not acting when people know I'm an EMT is an option that state laws take away from me.  And someone who sees me pass an accident scene need only look at my back window to know that I'm an EMT (and they have to look really close to see it).  Getting that and my plate number, turning them over to law enforcement, and I'm potentially in a world of hurt.  If I'm in uniform driving home, I have to stop unless someone else is already on scene.  I live in a small town now, where people know me by face, and not just a uniform that stops at the gas station on my way to work.  They recognize me and know what I do for a living.  If I'm in there out of uniform, see someone fall, and do nothing, and the regular clerk looks at me and says "You're an EMT, aren't you going to help him?" and I don't, I could be found negligent in a civil and/or criminal sense.

On the other hand, is someone with or without basic first aid training any less negligent if they take it upon themselves to try and manipulate what they suspect is a sprain, and cause a closed fracture to become open?

I am not a CAP commander and most decidedly do not make policy, but having a medical section staffed by licensed professionals that puts hands on patients for anything other than a true emergency endangers the corporation.

Period.

Any less liability than having such resources available and not properly utilizing them?

As a practical matter, most TACS can tell if a problem is something that can be dealt with with moleskin and band aids, or if we need to call 9-1-1.

Maybe where you are.  Here not so much.  It's not necessarily a training issue as a common sense issue.  EMS was it's own worst enemy when it came to "Dial 911" campaigns.  That's the first thing anyone thinks when confronted with a medical problem.  Johnny fell off his bike and bumped his chin...call 911.  Susie's got a sniffle....call 911.  Jimmy's got a tummy ache....call 911.  Mary stubbed her toe...call 911.  What I see in my daily experience is that people think 911 is going to work miracles (thank you William Shatner).  People think we're lazy when we tell them Susie can go see her doctor in the morning, or we just put a bandaid on Johnny's scraped chin, that they don't need to go to ER.  We're not lazy, we're just trying to keep resources available for the person who really needs us.

For all the stuff in the middle ("twisted ankles", abdominal pain, high fevers, etc. should be seen by some sort of (non-CAP) professional.  These days, the most accessible folks like that are typically the urgent care clinics (aka Doc in the Box).  It's not that big a deal to have the TAC talk with Mom, and then get the kid transported to the clinic where they are usually seen in less than an hour.  The kid's insurance pays (Mom gives a credit card over the phone for any co-pays), and everybody's happy.

And that's what we do, except that that twisted ankle goes with a SAM or pillow splint and an ice pack.  Nothing we can do for anyone else except take them downtown.  The only difference is that we have to use a hospital ER because there aren't any urgent care centers in town.  What would you do if you called a parent and said "Sally's got abdominal pain, we're going to take her to the ER to be seen," and the parent says "Don't you dare!  She's just homesick, she did the same thing at camp last summer."  Then what?  It happened to us a couple of years back, and the commander looked at me and said "You're an EMT, what should I do?"  Who pays if insurance doesn't, or the parents don't have it, or they won't cough up for co-pays?

The biggest drag is the loss of an adult who escorts the troop to the clinic and waits around.

That's what I use chaplains for.   

Couldn't agree with you more there.   

[Eclipse]

Unfortunately, not acting when people know I'm an EMT is an option that state laws take away from me.  And someone who sees me pass an accident scene need only look at my back window to know that I'm an EMT (and they have to look really close to see it).  Getting that and my plate number, turning them over to law enforcement, and I'm potentially in a world of hurt.  If I'm in uniform driving home, I have to stop unless someone else is already on scene.

If that's the case, you're not in CAP when you are responding, regardless of what uniform you are actually wearing. Your state's "duty of care" trumps CAP's regs, but you can't expect them to provide you insurance.

This exact conversation has been going on for years, and will continue until something changes at NHQ.   If you search this board and cadet stuff you will find LOTS of threads about this, or related topics in the ES forums with providing care to victims - same exact issues, with the small extra wrinkle of being in more remote areas where EMS isn't "right there".  Thus we now have a "first responder school" at NESA despite the fact that the statistical reality of CAP being the first on scene in a crash where EMS is not also in the area, approaches zero.

If you hop over to the CAP Health Services Yahoo Group and start this discussion we'll never hear from you again,  because frankly there is no answer, and many members argue that the ambiguity is left in place by design to allow trained professionals to act, while still absolving CAP of official sanction of the actions.

That leaves the member(s) stuck in the middle.

Look anywhere else in the organization and you will find little to no gray area.

Want to fly - no problem.  What you can and cannot do in, with, or near an airframe is spelled out in excruciating detail.

You can't pick up a CAP radio without at least 4 hours of in-house training.

But start talking about HSO issues, and the detail fades away.  Heck, there isn't even a specified standard of training for very basic first aid we >do< need and are discouraged to use.

Many people argue that floating around in a $300,000 Volkswagen with wings is as, or more, dangerous
that having CAP HSO's provide routine emergency care.  After all, we're allowing outside agencies and organizations (i.e. FAA & flight schools) to certify that someone is capable of operating the controls of an airplane in a safe manner. So why can't we allow EMT's, and Dr's, also certified by outside agencies, to use their skills?

The trouble with this analogy is that anything short of an actual crash is generally handled as an administrative issue internally.  There's very little chance of being sued because you "almost crashed", or didn't fly.

[Major Lord]

I don't believe that there is any regulatory authority that states or infers that a
layman can provide even parental levels of first aid "boo-boo" care. The regulations ban both professionals and laymen from rendering any routine medical care, and only permit medical aid of any kind in life-threatening emergencies. Scope of practice or level of training is not relevant unless exceeded.

There are no exemptions for TAC officers to render ordinary first aid, hand over a band-aid, moleskin, etc. or even instruct a member to lie down if they feel faint. Many of you apparently believe that there is some basis for providing non-emergent care, based on our standard practices and common sense. Clearly our regulations were meant to replace common sense. ( this from the people who spent out money on NASCAR, sweet mother of Buddha!)

The regulations are in conflict with morality, best corporate practices,  our duty of care to our cadets and their parents, and possibly law. So I ask you, which should we change?

Change the regulations to allow encampment staff  (preferably, but not necessarily medical professionals) to permit parental- level first aid and medical care!  Band-aids for boo-boos, antaseptic, Other-The Counter medications ( We could make a list of acceptable ones and have parents check of any they would decline) This would allow us to drain and dress blisters, apply band-aids, ice-packs, possibly even hand over a couple of Tylenol or Benadryl if required. In other words, take care of the cadet and keep the activity going, instead of calling parents for every complaint or going to the ER for every alleged injury. A real life medical professional should be present at an encampment, but only for rendering true emergency care, and triaging the endless stream of cadets who suddenly developed asthma, migraines, scurvy, or some other nasty and imaginary disease immediately upon having a three foot high " Sergeant Major" of the encampment do his level best to politely motivate them to run or do pushups.... Ideally, Emergency room nurses or doctors should be used for triage. Many other practitioners will buy into a Cadets' complaints way too much, and don't want to tell Cadets that pain in their legs and shortness of breath are normal when running....And having a Cadet in that position? Are you out of your minds?!!! (they may look sweet, but they would kill us and everyone we love given half a chance!)

Major Lord

[Slim]

If that's the case, you're not in CAP when you are responding, regardless of what uniform you are actually wearing. Your state's "duty of care" trumps CAP's regs, but you can't expect them to provide you insurance.

Oh, I have no such expectation.  My employer provides me with liability and malpractice insurance.  As long as I act within the accepted standard of care, and within my training, with the equipment I have available, I'm covered.

This exact conversation has been going on for years, and will continue until something changes at NHQ.   If you search this board and cadet stuff you will find LOTS of threads about this, or related topics in the ES forums with providing care to victims - same exact issues, with the small extra wrinkle of being in more remote areas where EMS isn't "right there".  Thus we now have a "first responder school" at NESA despite the fact that the statistical reality of CAP being the first on scene in a crash where EMS is not also in the area, approaches zero.

If you hop over to the CAP Health Services Yahoo Group and start this discussion we'll never hear from you again,  because frankly there is no answer, and many members argue that the ambiguity is left in place by design to allow trained professionals to act, while still absolving CAP of official sanction of the actions.

That leaves the member(s) stuck in the middle.

Look anywhere else in the organization and you will find little to no gray area.

Want to fly - no problem.  What you can and cannot do in, with, or near an airframe is spelled out in excruciating detail.

You can't pick up a CAP radio without at least 4 hours of in-house training.

But start talking about HSO issues, and the detail fades away.  Heck, there isn't even a specified standard of training for very basic first aid we >do< need and are discouraged to use.

Many people argue that floating around in a $300,000 Volkswagen with wings is as, or more, dangerous
that having CAP HSO's provide routine emergency care.  After all, we're allowing outside agencies and organizations (i.e. FAA & flight schools) to certify that someone is capable of operating the controls of an airplane in a safe manner. So why can't we allow EMT's, and Dr's, also certified by outside agencies, to use their skills?

The trouble with this analogy is that anything short of an actual crash is generally handled as an administrative issue internally.  There's very little chance of being sued because you "almost crashed", or didn't fly.

Oh, I know.  Ned and I have had this discussion once before over on cadetstuff.  While I see and agree with his position, I don't see it in the same way.  I've tried to make the point that we don't use our medical staff do do anything beyond basic first aid and emergency, life-saving procedures.  Which, in my interpretation of CAPR 160-1, section B, paragraph 6, subsection a, is an acceptable practice.  Subsection b is also religiously complied with.

A lot of laypeople are applying a standard of care to us without knowing what that standard is.  A neurosurgeon couldn't do emergency surgery with a pocket knife, a hacksaw, and a pair of pliers, but they can slap a band aid on a cut, or some 4x4s on a cut head.  A lot of the basic care EMS provides is nothing more than standard first aid stuff.  The more advanced procedures (medications, IVs, etc) are always done via doctor's orders or standing protocols.

[Ned]

Almost too much to respond to here.  I'm sure I'm going to miss a few points.

First, Alan, I think you have created a false dilemma here.  I can only agree that there is no special provision in the regs or other guidance that would allow TAC officers to perform routine first aid or medical care that other members could not perform.

But that is not very surprising because the kind of "boo-boo" care you described so well is neither First Aid nor medical care.

For the purpose of this discussion, let's go ahead and call it Boo Boo Care.

First, we know that putting on a band aid or moleskin is not First Aid because first aid is defined variously as

• "Emergency treatment administered to an injured or sick person before professional medical care is available," or
  
  
• First aid, immediate emergency treatment given to an injured or ill person", or
  
  
• "First aid is emergency care given immediately to an injured person."

(Those are the first three definitions I get when I googled "first aid definition.")



The two common factors here are that first aid is "emergency care," and that it is preliminary to professional treatment.

I don't think anyone in the world would classify a blister, minor cut, or someone who looks faint (your examples) as an "emergency."

Hence, caring for those condictions is NOT first aid -- it's Boo Boo Care.

And caring for these conditions is not "medical treatment" either.  Common sense tells us that medical treatment is treatment by medical professionals.  To hold otherwise makes the whole phrase meaningless.

Mom doesn't perform "medical treatment" by moleskinning a blister.

(BTW, Mom doesn't do "medical treatment" if she were to perform surgery on Junior, either.  She simply commits a crime.)


I'm sure there are definitions of "first aid" floating out there that don't include the "emergency" part, but take a look at how the 160-1 discusses it:

Medical care within CAP is limited to emergency care, only (i.e. first aid and stabilization) within the training and qualifications of the person redering such care, until such time that private professional or authorized military care can be obtained.

This reinforces the second element -- that "first aid" is something given in emergencies where it is anticipated that professional medical care is required.

(That's why it is not "Last Aid."  )

Nobody seriously expects the moleskinned cadet to be seen by a medical professional, hence the act of applying moleskin is NOT first aid.  It is Boo Boo care.



And Chris, I hear the conflict you are describing about your duties under state law as an EMT and CAP's requirement that you not perform routine care.

First, I suspect that Michigan law only requires you to act in emergencies.  IOW, I don't think many EMTs have been prosecuted for walking by a kid with a blister  without stopping and rendering professional care. 

ANd of course in bona fide emergencies, CAP members are permitted to render first aid within their skills and training.

Doesn't sound like a conflict to me.

But even if the Michigan law requires you to take action in non-emergencies, all that does is put the election in your hands.

You may remember the big controversy when CAP said we could not carry concealed (or other) weapons while on duty.  All the various cops and similar officials screamed that they were "required" to carry while off duty since they are cops 24/7 etc.  When checked, it turned out that less than 1% of the cops in the country work for "mandatory carry" departments.  It really did not turn out to be as large a problem as it first appeared.  And ultimately if your civilian responsiblities prevent you from performing your CAP duties, then you may well have some choices to make.  Going to jail for following some CAP regulation is a little much to ask of anyone.

I'm sure I've missed a few points here.  Sorry.

Ned Lee
Former CAP Legal Officer
Former Police Officer
Former EMT

[Ned]

Now that I'm home I can see I did miss a few important points.

I am not a CAP commander and most decidedly do not make policy, but having a medical section staffed by licensed professionals that puts hands on patients for anything other than a true emergency endangers the corporation.

Period.

Any less liability than having such resources available and not properly utilizing them?

YES.

Our official position is that we don't provide routine medical care.  Period. 

We are never going to get sued for failure to provide routine care -- especially when we said we weren't gonna in the first place.  Even if we had a doctor and a clinic hiding in the closet and we could have provided some routine care.

(Remember, we can provide first aid in true emergencies. But even if all we do is call 9-1-1 and await EMS we will be fine.)

What would you do if you called a parent and said "Sally's got abdominal pain, we're going to take her to the ER to be seen," and the parent says "Don't you dare!  She's just homesick, she did the same thing at camp last summer."  Then what? 

I'd do what any ordinary prudent person would do. I would tell Mom that based on the abdominal pain complaint and the fact that Mom isn't here, we are going to take her kid to the ER unless Mom can show up here and sign the kid out to do her own thing.

It happened to us a couple of years back, and the commander looked at me and said "You're an EMT, what should I do?" 

Let me gently suggest that an EMT should not be part of this decision tree for the reasons we have described at some length.  The only helpful input you might have would have something to do with the "life-threateningness" of Sally's complaint of abdominal pain.  A lay person knows that significant abdominal pain is sometimes very serious and could signify Very Bad Things, and sometimes may turn out to be nothing more than an over-ripe MRE.  And lay folks know that lay people do not have the skills and abilities to know the difference.  That's why we take them to the doc.

An EMT could of course do a complete secondary survey, check for things like fever and rebound tenderness, and actually understand the significance of the presence or absence of such things.

Accordingly, any input you give is almost certainly medical care.  Most likely of the routine type (unless we can somehow make this tummyache an emergency situation.)  And if you are wrong, Very Bad Things could happen to the corporation.

This is a decision that should be made by responsible adult - a TAC or a member of the CoC.

Who pays if insurance doesn't, or the parents don't have it, or they won't cough up for co-pays?

Good question.

And the answer is Mom and Dad are on the hook for all of Junior's medical costs.

Period.

Even if they say that they won't pay.  It's a matter between the hospital and the family.  And as you know, they are quite used to dealing with it.  Lots of people don't want to pay their medical bills, and ERs have to provide the care regardless.

But if you want to be nice and pay for it, by all means do so.  I know I have done exactly that myself when uninsured cadets show up at encampment and Mom and/or Dad live 400 miles away and can't/won't come and/or help.

But you don't have to.  And neither is CAP, Inc liable.

[Jolt]

Is routine medical care the same as a routine medical assessment?

[Slim]

Ned,

Are we in agreement that boo-boo care is NEITHER routine medical care or emergency first aid?  Would you be willing to go so far as to stipulate that it doesn't matter who provides said "boo-boo care"?

Are we in agreement that properly immobilizing a suspected fracture constitutes emergency medical care/first aid ("Stabilization" as stipulated in the 160-1)?

Are we further in agreement that one of the duties of an HSO is to advise the commander on issues pertaining to the health and welfare of his/her members (as paraphrased from CAPR 160-1, Sec C Para 7)? 

7. CAP health service personnel are responsible for advising CAP commanders and unit personnel on the health, fitness, disease and injury prevention, and environmental protection of CAP members relevant to CAP activities, with special emphasis on those members involved in flying, emergency services and disaster relief activities, field exercises, encampments, and special activities.

In fact, as I read this section, I'm finding myself developing the opinion that HSOs should be present (in fact, required) at large activities like encampments.  Also note subsection h of section C, para 7:

h. Assist in providing necessary health service training materials, supplies, and equipment for unit missions or special activities, including first aid and blood-borne pathogen/disease prevention kits.

So, an HSO (and EMTs/medics do qualify for this duty according to the reg) has the duty to assist in providing first aid supplies, but can't be allowed to use them?

In the instance cited where my opinion as a medical professional was sought, I advised the commander that we already had consent to treatment by way of the CAPF 31, and took the cadet downtown.  A lay person would be more inclined to write off a tummy ache as no big deal.  As a trained professional, I know all of the things a tummy ache could be, and know that the only way to know for sure is to have the patient taken to an ER for evaluation and treatment (to include x-rays, ultrasounds, bloodwork, etc.) by a doctor.  That's why my opinion was sought, and I advised the commander appropriately, within the scope of my qualifications and experience.

Again, where I think we're in disagreement is in what constitutes an emergency, and emergency first aid/treatment.  A freely bleeding scalp laceration (keeping in mind that the thinnest skin on the body is on the head, and head wounds tend to bleed a lot)?  An ankle that could be broken, and needs to be immobilized/stabilized before moving the patient?  Assisting a cadet with administering an EPi pen after a bee sting when signs of allergic reaction are present?  Dressing a laceration on the arm to control bleeding while waiting for EMS, or during transport to the ER.

I'll stipulate that these aren't too routine, even for a physically challenging activity like encampment.  However, if an encampment is so physically demanding that injuries like these become routine, you need to take a long, hard look at your ORM matrix and safety protocols.

I can dress a blister just as well as the next guy; that isn't the contention now that you've stated your opinion that this isn't medical treatment at all ("Boo-boo care").  My concern comes from the situations I've described, where I may be held liable for my inaction professionally, or for my actions by CAP.  Do I do what i know is morally right as a human and medical professional, or do I do what is deemed right by regulations? 

"Above all else...Do no harm"--The first rule of medicine.

In the end, I'm sure we're going to have to agree to disagree here.  I see the medical program used at my encampment as being well within the purpose and intent of the CAPR 160-1.  I have no issue with the way we do things here, and neither does my chain of command, else we wouldn't be doing it.  Your mileage certainly varies.  Perhaps another hang-up is the terminology I'm using.  Would it make more sense if I called it a health service program?

Either way, it's been a productive, educated discussion.  Thanks 

[Ned]

Ned,

Are we in agreement that boo-boo care is NEITHER routine medical care or emergency first aid? 

Yes, when performed by non-HSOs, like TACs or other CP senior members.

Would you be willing to go so far as to stipulate that it doesn't matter who provides said "boo-boo care"?

(Oooh.  "Stipulate."  This from the same guy who coined "Boo-Boo Care."  )



No.  In my view, HSOs should not administer Boo Boo care because care performed by medical professionals is most circumstances will amount to the dreaded (and prohibited) "routine medical care," essentially by definition.

  And, yes, I understand that this means that trained profesionals can cannot do some "medical things" (really Boo-Boo care) that TACs and others may routinely do.  While that seems like a paradox, it is simply is a way to prevent the exception from eating the rule (or the camel's nose under the tent or what ever your favorite metaphor that describes a slippery slope problem might be.)

If we stick to a model that says TACs and others can provide the same kind of care that Mom or Dad could (in loco parentis), and while simultaneously prohibiting HSOs from performing routine medical care, the corporation is not endangered.  And remember, in a true emergency, anyone can perform first aid within their skills and abilities.

Are we in agreement that properly immobilizing a suspected fracture constitutes emergency medical care/first aid ("Stabilization" as stipulated in the 160-1)?

Yes, assuming a reasonable person would suspect a fracture that would benefit from imobilization and the victim is to be subsequently seen by a doc.

Are we further in agreement that one of the duties of an HSO is to advise the commander on issues pertaining to the health and welfare of his/her members (as paraphrased from CAPR 160-1, Sec C Para 7)? 

Of course.  HSOs are important in advising commanders about such things in general, and even about specific concerns about a given member based on something like a review of the medical portion of the activity application.

Example:"Hey boss, after going over the apps, it looks like there will be three kids attending with ADD/ADHD; we should probably alert the chaplain and their TACs to watchful for signs of stress or behavioral issues.  Also, there are two troops bringing their asthma inhalers.  Make sure that these are not collected and held by the staff, since the kid might need it at any time."

But this should not be stretched to providing routine care and diagnosis dressed up as advice.

Example:  "Hey boss, my job is to give you health advice about our members at encampment. I have performed an examination of Cadet Jones and my 'advice' after looking at the x-rays is to take this kid to the ER."

See the difference?

In fact, as I read this section, I'm finding myself developing the opinion that HSOs should be present (in fact, required) at large activities like encampments. 

While I would support the general notion of having HSOs at all activities, I think it would be a very serious error to require it.

First, as a practical matter we simply don't have enough qualified HSOs of the right type (debateable, but probably LVN or better,) to give us 10 days each summer for an encampment.  If we required such a thing, we would likely simply wind up having to cancel a significant percentage of the encampments without adding much in the way of value to the activities that do have an HSO in attendance.

We have been doing encampments for over 50 years in almost every wing, and the great majority of them have been done safely without an HSO. 

Second, as I touched on above, our "HSO tent" is a very large one, and covers virtually the whole range of the allied health professions including not only docs, nurses, PAs, paramedics, and EMTs, but also dietitians, psych techs, and even optical technicians.

I'm not sure having an optical technician at encampment would be very helpful. 

Also note subsection h of section C, para 7:

h. Assist in providing necessary health service training materials, supplies, and equipment for unit missions or special activities, including first aid and blood-borne pathogen/disease prevention kits.

So, an HSO (and EMTs/medics do qualify for this duty according to the reg) has the duty to assist in providing first aid supplies, but can't be allowed to use them?

Of course HSOs (along with anyone else) can use first aid kits for giving first aid in a genuine emergency.  But they cannot use the contents of the first aid kit for providing non-emergency care (routine care) or even Boo-Boo care.

In the instance cited where my opinion as a medical professional was sought, I advised the commander that we already had consent to treatment by way of the CAPF 31, and took the cadet downtown.  A lay person would be more inclined to write off a tummy ache as no big deal.  As a trained professional, I know all of the things a tummy ache could be, and know that the only way to know for sure is to have the patient taken to an ER for evaluation and treatment (to include x-rays, ultrasounds, bloodwork, etc.) by a doctor.  That's why my opinion was sought, and I advised the commander appropriately, within the scope of my qualifications and experience.

I don't want to get into commenting on the specifics of what y'all did or didn't do, but I would suggest that what you have described supports a conclusion that the commander was relying on professional medical advice in making her/his decision.  And that's extremely dangerous whevever it is not a true emergency situation.

Again, where I think we're in disagreement is in what constitutes an emergency, and emergency first aid/treatment. 

Then let's clear that up.  Here's the screen I get when I Google "define medical emergency.".

• means an Accidental Injury or a condition that occurs suddenly and unexpectedly and is life threatening or could result in permanent damage if not treated immediately. ...
  
  
•   A medical condition manifesting itself by "acute symptoms of sufficient severity-including severe pain-such that a prudent layperson could reasonably expect the absence of medical attention to result in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any ...
  
  
•   A medical emergency is an injury or illness that poses an immediate threat to a person's health or life which requires help from a doctor or hospital.
  
  
•   'Emergency Medical Condition' means a medical condition manifesting itself by acute
  symptoms of severity (including severe pain) such that a prudent lay person, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
  (a) placing the health of the individual in serious jeopardy;
  (b) serious impairment of bodily functions; or
  (c) serious dysfunction of any bodily organ or part.
  
  

I'm sure there are more out there.  There are probably some good ones in the Michigan Compiled Statutes and perhaps one of your EMT text books.

So with these definitions in mind, let's take a look at your examples:

A freely bleeding scalp laceration (keeping in mind that the thinnest skin on the body is on the head, and head wounds tend to bleed a lot)? 

Well, I suspect if the lac is gaping or would benefit from sutures, then it is probably the kind of thing they were talking about when they talked about "requiring help from a doctor or hospital," or could result in "permanent damage," so yup in my lay opinion, this could qualify as emergency and accordingly and CAP member (inlcuding HSOs) could render first aid.

An ankle that could be broken, and needs to be immobilized/stabilized before moving the patient? 

Pretty much the same answer, the suspected fx needs to be seen by a doc and failure to set a fx could result in permanent impairment of a body part.

My concern comes from the situations I've described, where I may be held liable for my inaction professionally, or for my actions by CAP.  Do I do what i know is morally right as a human and medical professional, or do I do what is deemed right by regulations? 

Again, I don't see the conflict here.  Assuming that Michigan only requires you to take action in emergencies, then there is no conflict at all with the CAP administrivia.

(If you can point me to the applicable MI law, I'd be happy to take a look at it.)

In the end, I'm sure we're going to have to agree to disagree here. 


Either way, it's been a productive, educated discussion.  Thanks 

Back at ya.

[sarmed1]

One of the options discussed in another thread........
I had a talk with the former National Commander at HMRS this past year.

He was very impressed with the core of thier medical support program.
...an Active Duty Doctor, offers his services free of charge with his own insurance for the duration of the activity.  (I wont get into the the other "issues" people have with their "medic" program)

His proposal was to develop a more comprehensive "medical unit" type program within CAP...ie Wing or Reginal "medical squadrons" wherer all of the HSO types are assigned.  When a large event occurs within that units area of responsability, CAP purchases (or activates) an insurance policy to cover the needed medical personnel for the duration of that specific activity. Cheaper and easier to manage than the idea of 100% coverage all day every day even if there is no CAP activity going on.

We also discussed the option of a program similar to the Chaplin program for the AF, where CAP HSO's meet the same "train and maintain" requirements as the AF counterparts, and are then "called to service" by the AF to provide support to its auxillary for events such as encampments, NCSA or even SAR/DR missions....

option 1 was agreed to be the easier (and quicker) of the two to accomplish.

He had asked me to develop a brief/proposal for him and legal to review for presentation...not sure where that would go with the regieme change (the current NC was in on this brief)

mk

[Ned]

Either may well work.

The former is similar to a solution I have used.

One year I "hired" an RN to work as a "encampment nurse."  She was not a CAP member.  She then went to the local urgent care center and coordinated some protocols from their MD medical director (presumeably in exchange for an agreement to send cases their way if parents and insurance would permit).

I then bought a commercial "camp nurse" liability policy through a broker that covered both the RN and CAP, Inc.  IIRC, it was about $10/head for the 10 day encampment period.

I coordinated all this through the corporate legal folks at NHQ and it worked fine.

The upside was that I had an RN on site to do the triage that we all need at encampment (which knee injury needs an x-ray, which should just be iced, etc) and happily it turned out that she was a terrific person who strongly encouraged cadets with minor health complaints to remain engaged in encampment.

The downside was the $2,500 or so for the policy.  Without question that is money that can be spent elsewhere at encampment if other arrangements can be made for medical care.


I only had to do this one time.  Since then we have been able to finagle sufficient mandays to hire a ANG nurse or medic to help us out.  This is kinda like your AD doc in the sense that it doesn't cost anything and as USAF folks, the liability situation is much improved.

Thanks for sharing possible solutions.

Ned Lee
CP Enthusiast
Former Legal Officer

[Eclipse]

An interesting solution, but a far-cry from the EMT cadet running around with a stethoscope.

And as you say, the cost is hard to justify when 9-1-1 is "free".

[PA Guy]

And as you say, the cost is hard to justify when 9-1-1 is "free".

Calling 9-1-1 for the minor problems treated and or triaged by the RN would, I think, wear out your welcome really fast with the EMS community.

[Jolt]

And as you say, the cost is hard to justify when 9-1-1 is "free".

Calling 9-1-1 for the minor problems treated and or triaged by the RN would, I think, wear out your welcome really fast with the EMS community.

Not to mention the response time would get longer and longer with each call.