Medical Sections

[SARMedTech]

Here's my point and I want to make it as uncomplicated as I can because I fear the more I talk the less I am understood: in "street" EMS there is a concept called load and go or stay and play. Basically this defines whether we hang around on scene and do all of our assessments and diagnostics and then make a decision as to how to proceed or whether the situation is serious enough that we slide a back board under the person, run to the back of the ambulance, and as the doors are closing, we are already running code three. I am willing to say that the vast majority of things that could happen to a cadet or officer out in the field are "stay and play" situations. But in those situations where that is not the case, I would like to have someone on scene who has the training and experience to say, for instance "that cadet is in shock, they can sue me later if they want and we are sliding into the back seat of the nearest truck and going like Hades. This is all I am saying and is really all I have been saying all along. As a side note, shock can occur for any one of a hundred reasons. I want someone standing over me when/if it happens who knows the severity of what just happened and whether or not we have time to stand around putting wet cloths on that persons forehead and waiting for them to be able to remember their own name. I want someone who knows the difference between compensating and decompensating shock and who knows that to do about both and the fact is that someone who spends a week at Hawk Mountain or similar facility and then wear the title "medic" is not that person. If a person falls and hits their head and is unconscious, does that "medic" know that the first thing you do is have someone clamp onto that persons head, hold it in line with the rest of their spine and not let go until that person is collared and taped down to a long board. Do they know how to take a blood pressure and determine to a fair degree of certainty from the numbers on the gauge whether or not that person has an internal head injury?  I dont think that they do having examined some of the "medic" programs curriculum. I dont even want someone putting a c-collar on my who has less than 6 months training to know when you should do that and when you shouldnt and when you do, which part of the persons head gets taped to the long board last and why. These are not issues of liability. These are issues of getting puffed up because someone hands you a certificate and calls you a "medic" and someone who has advanced anatomy and physiology, diagnostics, etc and has been able to pass a national exam that tells them when the medical spit is hitting the spam. How often does a cadet fall off a rope ladder and get hurt..I dont know because know one has been able to produce those statistics for me. But lets have a CAP officer answer this one: if thats your cadet who falls off that rope ladder or slips in the mud and smacks his head on a rock, do you want a "medic" or do you want someone with an emergency medical license issued by an authorized state department of public health and signed off by an MD to take care of your cadet?  It really IS that simple. Because in matters of life or death, liability is or at least should be and after thought and the fact is that that "medic" has a far greater liability than someone who has trained for a year or so to make these assessments. Can that "medic" explain in a court of law why he decided to get a couple of the brawnier cadets to pick that head injured cadet up and carry him to his bivvy and lay him down and let him rest rather than having him immediately assessed by someone who knows what in blazes they are looking at? I doubt it. I would love to be proven wrong and anyone who wants to pay for me, at 33 years old, to observe at Hawk Mountain or any similar program is welcome to do all they can to prove me wrong. It aint gonna happen.

[SARMedTech]

Before Hawk Mountain instructors and graduates get out the flamethrowers, I want to say this definitavely: My posts about EMS getting involved with CAP and EMTs vs "Medics" has nothing to do with my ego or anything of the sort. It has do entirely with how best to keep our members safe as they do what can be dangerous work. I didnt get into EMS because I enjoy trying to beat the life back into someone with CPR or getting my uniform soaked in someone else's blood from a pumping artery. I got into it because I have something of a facility for medicine and because I genuinely want to help people when they need it most.

I will now stand down and prepare copious numbers of burn dressings.

[fyrfitrmedic]

Before Hawk Mountain instructors and graduates get out the flamethrowers, I want to say this definitavely: My posts about EMS getting involved with CAP and EMTs vs "Medics" has nothing to do with my ego or anything of the sort. It has do entirely with how best to keep our members safe as they do what can be dangerous work. I didnt get into EMS because I enjoy trying to beat the life back into someone with CPR or getting my uniform soaked in someone else's blood from a pumping artery. I got into it because I have something of a facility for medicine and because I genuinely want to help people when they need it most.

I will now stand down and prepare copious numbers of burn dressings.

FWIW, no flames from here.

[RogueLeader]

I think you are right on.

[Eclipse]

SARMed, I see your point and have a very easy, quick solution - dial 9-1-1, and let the pros do it.

If the event is SOOOO rugged and "Leet" that its in accessible to EMS, contract a pro.

Either way, it provides the services needed, without risk to a members liability.

[RogueLeader]

What if that member IS who 9-1-1 would have sent, if he wasn't at the event?

[arajca]

If they operating as part of CAP, they are not part of the 911 system, even if they are normally part of it. I don't think any EMS system is so hard pressed that they only have one person to send out.

Now, if you are there and sign out of the activity and lose the CAP uniforms, then feel free to act as the outside EMS personnel.

A slightly diferent perspective: I am a volunteer Haz Mat Tech. At work, I have no haz mat tech level duties. When an incident occurs at work, unless my boss tells me to go, I do nothing. I have discussed it with the company legal folks and the decision was that I could, IF I where to be willing to assume FULL liability for anything that happened as a result of my actions. However, if I punched out and responded as part of the haz mat response, I would not be considered an employee and the liability concerns are not an issue. BTDT.

[SARMedTech]

SARMed, I see your point and have a very easy, quick solution - dial 9-1-1, and let the pros do it.

If the event is SOOOO rugged and "Leet" that its in accessible to EMS, contract a pro.

Either way, it provides the services needed, without risk to a members liability.

First of all, I am a "pro".  EMS is what I do for a living. And youre not going to be able to get an EMS crew, contracted or not, to sit at a week long cadet encampment 24 hours a day. As I have said so often, its not an issue of liability. Its an issue of CAP leadership not wanting to spend money. They have it to spend, we have been over how little it would cost to cover me and just yesterday I was having lunch with a trauma doc friend, and he informed me that all CAP would need to do would be to contact the local trauma center where the event was going to be covered, say we have a liability covered EMT as our health officer out here and the ER would just assign whoever was going to be on duty as the medical point of contact, which by the way, is what they do anyway. People keep talking about medical direction and supervision. Each and every EMS region in the country has its own medical director under whose license all EMTs and Paramedics in that region operate. However, it is not that single doctor who an EMT or Medic calls when they need a question answered or orders for a drug, procedure, etc. They call the local ER and whoever answers what is usually called some variant of the "MedLine" which is who ambulances call when they are inbound with a patient, and they get whoever answers the phone. Often this is a nurse and if a doctor is needed, she goes and gets one. Ive written several posts lately saying Im willing to operate as an EMT within CAPs current regulations until and unless the organizations is willing to pony up the cash for liability. Its the people who seem to be afraid of having an EMT out there, like we are going to deprive you of the opportunity to use your first aide skills, that keep sqwalking. Fine. The horse is dead. All I have continued to say is that if a cadet or officer is seriously hurt, I am going to do what is necessary to take care of them regardless of liability and if the State DOPH wants to pull my license after a due and proper hearing and investigation, then they can go write ahead and do it. It really is the non-medically trained among us or those who have not done the research that I have into this issue that are doing all the hollering. Do you want to wait for an EMS team to arrive. Fine. If you are the officer in charge, you may tell me so and to avoid getting 2b'ed I will stand down and let a persons condition deteriorate until EMS arrives.

[SARMedTech]

If they operating as part of CAP, they are not part of the 911 system, even if they are normally part of it. I don't think any EMS system is so hard pressed that they only have one person to send out.

Now, if you are there and sign out of the activity and lose the CAP uniforms, then feel free to act as the outside EMS personnel.

A slightly diferent perspective: I am a volunteer Haz Mat Tech. At work, I have no haz mat tech level duties. When an incident occurs at work, unless my boss tells me to go, I do nothing. I have discussed it with the company legal folks and the decision was that I could, IF I where to be willing to assume FULL liability for anything that happened as a result of my actions. However, if I punched out and responded as part of the haz mat response, I would not be considered an employee and the liability concerns are not an issue. BTDT.

Again, I dont remember what your EMS status is. But talking EMS and HazMat is apples and oranges. HazMat is not medical, except insofar as they keep a hazardous problem from affecting peoples health by containing it. Since we arent likely to need the glow worms at an encampment, I fail to see where this is relevant, but if a cadet spills his MRE on himself and it starts to eat his uniform, rest assured I will give you a call. All along what I have been talking about, it caring for the run of the mill injuries and assisting in the event of a major trauma should one occur until an EMS unit can be summoned and arrive. And when you start using the word "any" you are in dangerous territory. We have an volunteer EMS system just down the road from me in a rural area, that has no response vehicles and there "EMS" crews are all first responder certified, only, because thats all their community would pay for. In the middle of the night, they literally respond about half the time in their pajamas with their first aide kits, some of them walking to the scene, and waiting the two hours until a full crew can arrive. There has been more than one instance where they have transported someone in the bed of a pickup. Is this what you want for cadets or anyone else you may in charge of. I have said over and over, especially recently, I will abide by what CAP regs say and what the NHQ boys and girls want. And then, as far as liability, its not going to be my neck on the block if someone with an allergy to bee stings dies in anaphylaxis waiting for EMS. Its going to most likely first be the Wing commander explaining to a judge and jury why there was no one in a camp full of cadets or on an operation that was taking care of people. "Well your honor, its like this. We just really didnt want to pay for liability. Actually there was an EMT there and he acted to the fullest extent of our regulations by packing ice on the sting and he did give CPR when the cadet stopped breathing, but you know, without oxygen and an AED which we just didnt want to pay for, the cadet died despite that big chunk of ice that our EMT did such a good job of holding on the cadets leg. I really dont undertand why that cadet died."  People have said that CAP cannot be held medically liable. Fact is, when you have people's kids out there, or some officer with a heart condition, the judge is going to want to know why no one was willing to assume such liability. And when the Wing commander tells the judge and jury "we didnt want to pay $104/year for EMT liability" and we didnt do the research into having medical direction available for that EMT" the judge is going to say, well now you can pay the liability out of your wing funds and then the wing just goes away because its bankrupt.  Am I talking worse case scenario, yes I am, because that is what EMS is about. And we just recently had a entire school district almost go bankrupt because it had only one nurse who floated around to about 15 schools and the resulting damages levied against them and for the parents of a child who didnt get his diabetic meds on time were so enormous that that district now has know extra curriculars of any kind so that they can pay out their installments of the judgement and punitive damage each month to this family and to the diabetic research group that the judge ordered the school district to contribute to. The school district appealed in federal court, and lost. Do you really think that a judge will hesitate to levy the same kind of judgement against CAP. He is going to want to know why do you have medical officers and nurse officers and health services officers and no liability to cover them? We could have a trauma doc as the physician officer out there with cadets or whomever and if he is away from the hospital for which he works, his liability isnt going to cover him either, same with the nurse.

[Ned]

I will abide by what CAP regs say and what the NHQ boys and girls want.

And then, as far as liability, its not going to be my neck on the block (. . .)

Its going to most likely first be the Wing commander explaining to a judge and jury  (. . .)

but, without oxygen and an AED which we just didnt want to pay for, (. . .)

People have said that CAP cannot be held medically liable. Fact is, when you have people's kids out there, or some officer with a heart condition, the judge is going to want to know why no one was willing to assume such liability. And when the Wing commander tells the judge and jury "we didnt want to pay $104/year for EMT liability" and we didnt do the research into having medical direction available for that EMT" the judge is going to say, well now you can pay the liability out of your wing funds and then the wing just goes away because its bankrupt. 

. Do you really think that a judge will hesitate to levy the same kind of judgement against CAP. He is going to want to know why do you have medical officers and nurse officers and health services officers and no liability to cover them?

Gosh, just a page or so ago you indicated that you understood, and while you disagreed with the resource/policy issues inherent in the decision not to have HSOs perform routine care, you were going along.

And then you write this.

I'm (almost) speechless.

I think I may have mentioned that I am a former cop and a lapsed EMT.  Indeed, my basic EMT rating is well over 20 years old.  I would be far out of my depth in commenting on specific medical condictions and procedures.  Like many former EMTs, I undoubtedly think I know more than I do and may well be dangerous in an emergency.

And while I appreciate that you have some legal knowledge, may I respectfully suggest that you may be equally out of your primary area of expertise in discussing the legal exposure of the corporation based on our policy.

For example, Wing Commanders do not talk to judges and juries.  That's why we have lawyers. 

Who know the law, and how to talk to juries.

But in your scenario (bad outcome bee sting), it is not actually very important guessing who is going to talk to the jury, since nobody is going to have to.  Lawsuits just don't happen like you are suggesting.

Really.

(Hint:  A huge difference between us and the unfortunate school district you described is that they DID offer limited routine medical care, but then did not deliver on their promise when someone relied on it.  We are in an entirely different position in CAP.  And deliberately so.)

Remember, we agree that we that having routine and emergency care available to members is a very good thing. 

But medical care is not free, and we simply don't have the resources to implement it as you have suggested.  If you recall, I shared with you how I had actually contracted with a local urgent care center for protocols for an encampment nurse (who was a non-member).  I know this can work.

But you are inconsistent in your projections of low cost.  While the basic liability policy for an EMT may well be a very reasonable $104/yr, we have discussed that that policy does not cover CAP, Inc.  And without corporate coverage, it just doesn't matter how much the EMT policy is.  It could be free, but the very existence of CAP, Inc is at risk.

And then, using your scenario, we are gonna need a $1k AED and a couple thousand dollars of oxygen equipment and trauma gear for each activity.  Which has to be maintained and kept up to date.

Anyway you look at this it amounts to hundreds of thousands of dollars a year, which we just don't have.

Finally, remember that all CAP members can and should aid each other in emergencies, like the bad outcome beesting you so vividly described.


Ned Lee
Former CAP Legal Officer

[Eclipse]

What if that member IS who 9-1-1 would have sent, if he wasn't at the event?

?

[SARMedTech]

Ned-

I had this big long post prepared in response to your latest and then decided to pair it down.

1. I understand and will abide by the "emergency stabilizing first aide" regulations set forth by CAP.

2. Because of the nature of the operations and exercises carried out by CAP cadets and CAP officers, there will be a time, if it has not happened already, where "emergency stabilizing first aide" will not be enough.

3. In the instance I gave of the beestung cadet going into anyphalactic shock, minutes mean the difference between having an airway and a heart beat and not having one. Those minutes are gained by the administration of an auto-injecting ampule of epinepharine (adrenaline).

4. Under CAP regs, I cannot do this, nor would I have the epinepharine in the first place due to CAPS regs.

5. You mentioned the cost of CAP outfitting all of these supplies. Most of us who are EMS trained already have our own "jump kits" full of trauma supplies which I suspect we would be willing to donate the use of just as we donate so many other resources when we sign up to volunteer. No, I am not paying for an AED/oxygen, but CAP should.

6. You have spoken about people working within their areas of expertise. I have spoken with many EMS providers within and outside of CAP. I think the consensus is if your certification is 20 years lapsed (no offense intended) but theres alot of new information and skills you might not have, just as I dont have your level of legal expertise (I assume you are a lawyer). You'll forgive me if I ask you just to hand me bandages when the spit hits the spam. Again, I would even ask my retired LEO father whose EMT card expired about the same time yours did to step aside.

7. Regardless of what it may seem, my whole motivation behind all of this is to keep you, other officers and cadets safe and when they arent safe to keep them for getting worse or God forbid, dying. I should think that would be something CAP could get behind. Because even if CAP wasnt found legally liable in a wrongful death, for instance (51% liable) the publicity, all of it bad, would certainly cause a problem.

My kit is packed with advanced first aide gear. I have one I would use for CAP, and one for the rest of the world. I will not excede CAP regs because I am a good and loyal member (read with a little sarcasm).

[Ned]

Son,

I really think we agree on more than we disagree.

We agree that it would be better if CAP members had better access to routine and emergency care at activities.

And I think we also agree that current CAP regulations absolutely prohibit HSOs from providing anything other than true emergency care.

And I also think we agree that the primary reason for the current situation is legal liability for our HSOs and CAP,in, and the associated costs for providing liability insurance.  (There are some other significant problems like nation-wide standards and certifications as well as status during federally assigned missions -- but we'll leave those for other threads.)

And I further understand that you wished there were some way to magically change that and allow you and other highly-skilled folks help our members.

I get that.  I really, really do.


But, you keep acting like these are some beauracratic rules designed to keep you from your True Calling in Life -- Savng Lives.

I appreciate the fact that you have worked as a legal assistant and researcher.  That's a great foundation for anything you would like to do in life.

The problem is that you are pretty much wrong on the law as it applies in this situation, and that is leading you to some false conclusions.

CAP does not carry medical liability insurance. It would in fact, still be liable for a tortious action, that is an action causing damages other than physical ones. 

I'm not sure what you are trying to say here.  CAP is, and always has been, liable in tort for any civil wrongs committed by the corporation or its members in the course and scope of their duties.  CAP is not, and never has been liable in tort, for members acting outside their course and scope. 

But we cannot be liable for the tort medical malpractice if we do not engage in medical care (save emergencies.)

We can of course, be liable for negligent supervision (or something like that) if we negligently allow a cadet to come to harm.  But the standard is that of a reasonable, prudent person.  An ordinary lay person.

And most decidedly NOT the standard of a medcal professional.

As for the AED, there is no liability necessary for them since they sit now in cabinets in shopping malls and are virtually impossible to misuse. No license or certification or liability is necessary. As for maintaining it, well, just turn it on and run a ddiagnostic on it before carrying it along to whatever the event. Maintenance is not carried out by any medical person but rather by the company that sold the AED and usually involved putting in a new battery.

Yep, all you need is the thousand dollars or so to buy it, and then you have one.  You do, or course, need to maintain it.  How much does that battery cost?  How often does it need to be replaced?  How many AEDs do we need to buy to cover all simulaneous activities in all 52 wings, plus a few spares?

Oh, how about all the other trauma gear, like the oxygen set up you mentioned was needed? 

Honestly, how much would we need to spend to equip an EMT with minimum gear needed  for an activity like a 200-person cadet encampment?  How much of that needs to be checked, replaced, and rotated when that EMT is back at her/his home unit?

Ive been able to show where liability expenses come from...what we havent seen is this mystery number of hundreds of thousands of dollars.

Look back a page or two and you'll see it (again.)

After we buy about a hundred AEDs (less than two per wing) and spend that intitial hundred grand, we are gonna need that pesky liability insurance to cover CAP, Inc for medical malpractice.  Go ahead and price that one out for me.  Check with any large broker.  Tell them it covers a couple hundred medical professionals ranging from EMTs to docs and has to cover 52 jurisdictions and should probably have a 20-50 million dollar coverage.

Go ahead.  I'll wait. . . . .


Does that couple of hundred thousand really seem so unreasonable?

I can assure you that if someone died because CAP has no emergency medical team, it would go to court, with the lawyers, and I can also assure you that various wing commanders and squadron commanders would be called as witnesses and when a lawyer asks why there was no medical care and the lawyer for CAP or whoever says there was but we didnt provide them with liability...well the parent of the aforementioned cadet is going to own alot of airplanes and trucks and comms equipment.

As Ronald Reagan said, "there you go again" telling us about who can sue who for what.  And you are incorrect.

Tragically, this organization has already lost a number of our members.  Even more sadly, some have died of conditions like MIs or trauma where indeed a full-fledged medical team standing by might have made a difference.

But so far, there has not yet been a significant recovery against the corporation for failing to have such a team standing by in all conceivable locations.

IOW, we've lost over a dozen cadets at encampments since WWII, and parents do not yet "own a lot of airplanes and trucks and comm equipment."

And what I'm trying to tell you is that is because we do not pretend to offer medical care that we do not have the resources to do adequately.  Not because we have been "lucky."

When someone prevents me from carrying out what I am trained to do by not having appropriate liability in place, the judge is going to say well that EMTs hands were tied, he couldnt do anything.

I know something about judges, and I can predict with some certainty that the judge will say nothing of the sort.

Because judges follow the law.

If you think I am giving worst case scenarios to jolt someone into action, I am, and will continue to until someone listens or someone dies from a lack of action, whichever comes first.

Like I said at the begining, we can both agree that it would be a good thing if members had better access to both emergency and routine care.

Now, let's talk about solutions . . .

[SARMedTech]

Ned-

See now I cant respond angrily because you called me "Son."

Somehow this posting got up when I had erased it before it was posted and replaced it with a much more productive one. Wait, that is the one I meant to post...whats up here.....Oh well.

I dont think that its actions being taken to keep me from my true calling. I live my true calling on a rotation of 24 hours on, 48 off, 52 weeks a year.


The kit I recommend be at all events and stowed with the Squadron, not taken home by the individual EMT, is called a S.T.A.R.T kit (Simple Triage and Rapid Treatment). It costs about $200.  Its very inexpensive to keep the kit current, stocked and maintained and in the hands of someone trained to use its contents could do alot of good.

I totally understand what your saying and defer to your greater legal knowledge. You say lets come up with some solutions. Im all ears, "Pop." 

[PA Guy]

As I have said before the only viable solution to this problem is to come under the Fed umbrella for tort protection.  With at least 52 different jurisdictions, varying protocols and standardized procedures and a variety of licensure, certifications and skill levels I don't see anyother way out.  We need something along these general lines:  http://ndms.dhhs.gov/teams/dmat.html

[Ned]

Logically, I can only think of two alternatives:

1.  Locate a bucketload of money (say a million or so for equipment, training, and insurance)., or

2.  A legislative fix that would serve as a sort of federal Good Sam law that would specfically protect volunteer medical providers working in and for non-profits. 

Beyond the normal hurdles that any leg program faces, this one would have the additional burden of likely being opposed by two huge lobbying groups -- both the AMA and the trial lawyers.  For both groups it is a simple pocketbook issue; for the AMA, any care provided by volunteers is probably care that would otherwise have been provided on a fee-for-service basis by one of their members.  For the trial lawyers, well, they  would simply oppose any limitations on liability in medical malpractice situations.  Lawyers make a lot of money on these kinds of cases.

Frankly, I'm not very optimistic about either option.  I'm hoping that the rest of you have some better ideas.

Thoughts?

[flyerthom]

PA guy was headed in the right direction.  But, we don't need to duplicate DMAT. Why reinvent the wheel? We need an MOU with them. We then train with them; giving us medical coverage and them increased transport and recon capability. It also trains both for better inter agency interoperability. If the MOU gave HSO's Federal Coverage we're golden. If it doesn't - at least our members would have a covered medical team on hand. And if they supplied EMT's to our ground teams -we'd be closer to NIMS or NASAR standards.
Cost would be minimal. And we may just get more disaster relief missions.
It's at least worth a look.

(modified for grammar error)

[PA Guy]

Another alternative might be something along the lines of the USCG Aux Health Services program.  In this program liability is assumed by the feds and credentialing is done through the USCG along with supervision.  Do I see the USAF doing this in my life time? Not really.

[PA Guy]

PA guy was headed in the right direction.  But, we don't need to duplicate DMAT. Why reinvent the wheel? We need an MOU with them. We then train with them giving us medical coverage and them increased transport and recon capability. It also trains both for better inter agency interoperability. If the MOU gave HSO's Federal Coverage we're golden. If it doesn't - at least our members would have a covered medical team on hand. And if they supplied EMT's to our ground teams -we'd be closer to NIMS or NASAR standards.
Cost would be minimal. And we may just get more disaster relief missions.
It's at least worth a look.

I wasn't suggesting CAP set up a DMAT.  I was thinking more along the lines of fed tort protection and the licensure/certification issues. 

[flyerthom]

PA guy was headed in the right direction.  But, we don't need to duplicate DMAT. Why reinvent the wheel? We need an MOU with them. We then train with them giving us medical coverage and them increased transport and recon capability. It also trains both for better inter agency interoperability. If the MOU gave HSO's Federal Coverage we're golden. If it doesn't - at least our members would have a covered medical team on hand. And if they supplied EMT's to our ground teams -we'd be closer to NIMS or NASAR standards.
Cost would be minimal. And we may just get more disaster relief missions.
It's at least worth a look.

I wasn't suggesting CAP set up a DMAT.  I was thinking more along the lines of fed tort protection and the licensure/certification issues. 

That would be ideal. Getting that by congress is the curve ball. An MOU would bypass that and give things to both. Either way is a solution.