Mixed messages about medical services

[Krapenhoeffer]

My rule of thumb has always been that anything beyond mom and chicken soup kind of care is outside our scope.  In a life or limb situation activate the EMS system and provide care until they arrive.  Conducting a daily sick call with the laying on of hands, routinely dispensing OTC or legend meds, giving injections or assisting in giving injections, these are the types of things I would consider medical care.  Handing out band aids, moleskin and having someone rest for few mins. I don't consider medical care.

What about the NCSAs that have sick calls run by CAP members... It happens people, and CAPTalk wannabee lawyers aren't going to stop it. Is it incorrect, yes. Is it happening, yes. Do the regs need to change, yes.

[Krapenhoeffer]

I appreciate your skill set however, the regulation would keep you from providing any other care; in or out of the ambulance.  As a CAP member, IMO, you would be taking our collective posteriors with you if you determined that the ambulance was "undermanned" and made decisions which may adversely effect the (now) patient.

This regulation, BTW, was authored by two very respected physician members of CAP.  One is our chief HSO and the other the chief of EM at a large metropolitan hospital.  Yes, our lawyers were involved too.  We live in very interesting times....

Allow me to explain, when I say figuratively deblouse, I mean to say that I would be signed out. That has always been my idea. And I wouldn't be the one determining if the ambulance is undermanned. The crew chief of the ambulance does.

If and when I board the ambulance, I'm not SM Krapenhoeffer, CAP. I'm Asst. Crew Chief Krapenhoeffer, <insert my municipality here> EMS.

[Ned]

CAP members at an activity may not under any circumstances render aid in anything other than a genuine life or limb emergency.

Exactly how far down the aid continuum does this go?

Good catch.  I forgot the word "first" in front of aid.  I went back and edited my post.

By definition, "first aid" is "emergency care given before professional medical care can be obtained.

CAP members can always render aid in an emergency, and I hope nothing I have said would discourage anyone from trying to save a life or limb.

The problems come when members - in good faith - try to push the boundaries of "first aid" to stretch it to cover any possible medical assistance in any situation.

So let's use your examples and take a look:

  For example:

- Cadet participates in CPFT.  Gets a little light-headed during the mile run.  Senior member walks cadet back to a bench, provides him with some water, keeps an eye on him while he recovers.  Is this a violation of CAP regulations?

Giving someone some water and watching them is not "medical care" nor first aid.  On these facts alone, there is no emergency in any event.

- Cadet trips and falls.  Scrapes hand, but doesn't have a first aid kit.  Asks for a band aid.  Are we to bring him to the ER to administer the band aid?  Or drive him to Wal-Mart to buy his own?

Similarly, a minor scrape is not an emergency under anyone's definition.  Handing someone a Band-Aid  Brand adhesive bandage (tm) is neither medical care nor first aid, and is perfectly acceptable.

- Cadet gets blisters at encampment, doesn't have moleskin.  Do we send him home?

I'm not sure why anyone would get sent home for blisters, so maybe I'm not following your question.  But handing someone a piece of Dr. Scholl's Molskin adhesive padding (tm) is not medical care nor is it first aid.

I know CAP members aren't going to be stitching up wounds or doing open heart surgery at a CAP activity, but what is the threshold for something being considered medical care?

Part of the problem is that there is never going to be a bright line definition that will work for every possible factual situation.  That's one of the reasons that common sense is needed in abundant supplies by our members and leaders.

Most folks define "medical care" as professional treatment given for an illness or injury.  Diagnosing, prescribing, or treating illnesses and injuries normally requires a medical license of some sort in every state.  There are common-sense exceptions for things like first aid and conditions that do not require medical care, which includes things like blisters, insect bites, bumps and bruises, etc.

No medical license is required for a Mom or Dad to put a Band-Aid (tm) on a minor cut, take a child's tempurature, or decide when it is time for a trip to the doctor.

Similarly CAP members with responsibility for the care of minor cadets can do similar sorts of things - and it simply isn't medical care.

But it isn't hard to thing of hypotheticals that get closer and closer to the line.  And while 99.9% of the situations we are faced with will have an obvious answer about what is or is not acceptable, sometimes - in that tiny percentage of cases - we will need to rely on our trained leaders to make a common sense decision.

[JayT]

I appreciate your skill set however, the regulation would keep you from providing any other care; in or out of the ambulance.  As a CAP member, IMO, you would be taking our collective posteriors with you if you determined that the ambulance was "undermanned" and made decisions which may adversely effect the (now) patient.

This regulation, BTW, was authored by two very respected physician members of CAP.  One is our chief HSO and the other the chief of EM at a large metropolitan hospital.  Yes, our lawyers were involved too.  We live in very interesting times....

Allow me to explain, when I say figuratively deblouse, I mean to say that I would be signed out. That has always been my idea. And I wouldn't be the one determining if the ambulance is undermanned. The crew chief of the ambulance does.

If and when I board the ambulance, I'm not SM Krapenhoeffer, CAP. I'm Asst. Crew Chief Krapenhoeffer, <insert my municipality here> EMS.

Krapenhoeffer, I think that you are reading to much into some things, and too little into others.

The fact of the matter is, and you know, is that an AEMT cannot practice their skills without ALS equipment. I'm a good EMT, but without a Zoll, a drug bag, a narcs kit, a tube kit, a trauma bag and an airway bag....there's really not much I can do, is there? I don't know about your state, but in New York, an ALS provider can only provide BLS care if they buff a call unless they contact medical control and are authorized to provide ALS care in that county ahead of time.

What situations do you think you are going to come across that requires anything beyond BLS stabilization? No one is saying that you can't provide emergency stabilization.

[Ned]

What about the NCSAs that have sick calls run by CAP members... It happens people, and CAPTalk wannabee lawyers aren't going to stop it.

But commanders, staffers, and any officer having genuine concern for the future of CAP can and should stop it.

Do the regs need to change, yes.

Non-concur.

The regs are written the way they are for simple and practical reasons.

CAP cannot be in the business of providing non-emergency medical care for the simple reason that we are not a medical provider.  Medical providers have things like standards, training, protocols for treatment, an adequate infrastructure to provide for oversight and quality assurance in all 52 wings, and most importantly, errors and omissions insurance to cover the inevitable errors that are made by all human beings, including medical officers (and lawyers).

Feel free to price out an insurance plan with any broker that would cover all of our health professionals in all 52 wings (and our overseas units.)  Be sure to tell the broker that you will need to cover not only physicians, PAs, and nurses, but also various kinds of medics ranging from Advance First Aid card holders through paramedics (with a lot of variety in between).  While reasonable minds will vary, I suspect that CAP, Inc will need at least $10-20 million in liability coverage (about a mid-range award for, say, a tragic mistreatment of a cadet rapelling accident that resulted paraplegia).

Tell me what the price you find is, but the last time NHQ checked, we were quoted something like a quarter of million dollars a year.  Which is another way of saying "a substantial dues increase for every single member."

(And, BTW, if I found an extra quarter of a million dollars in CAP's budget, I would probably spend it on other things.  Like cadet scholarships, o-rides, and travel money for basic encampments.  To start.)

Once you have found us some inexpensive insurance, take a moment and think about the infrastructure necessary to provide training and supervision for all of our HSOs in 52 different jurisdictions.  That's a lot of record-keeping and doctrine creation.

Finally, take an additional moment and price out the standardized equipment necessary for all of our medical folks to meet the minimum standards of care in each state.  Things like AEDs, oxygen sets, extraction collars, splints, litters, cardiac monitors, etc.  Don't forget to price out routine maintenance and upkeep, including rotation of supplies.

NHQ is not a cabal of evil people trying to think of ways to deprive you of opportunities to serve your community.  Indeed, it is quite the opposite.  But NHQ and the National Staff do have the responsibility to think policies through carefully, examine the costs and benefits, provide that data to our volunteer leadership that makes the final decisions.

Which they have - the result is a clear, unambiguous regulation that forbids members to render medical care except in genuine emergencies.

And in an emergency, CAP members can and should render all possible care within their resources and training.

Ned Lee
Former CAP Legal Officer
Former EMT

[RiverAux]

Ned, what are your thoughts on the incident that prompted this thread?

[Ned]

Ned, what are your thoughts on the incident that prompted this thread?

Hard to say.  The only two factoids in the Volunteer article were "roving safety patrols" - which seems fine on it's face assuming adequate senior supervision, etc. - and " first aid teams."

If the teams are truly responding to genuine emergencies and providing first aid ("emergency care given before regular medical attention can be obtained"), then I don't see a problem with the regulation.

In the only actual medical incident described, the cadets passed out a cold compress or two and immediately summoned professional medical help (the nurse) .  That doesn't sound like rendering medical care or first aid to me.

And I must say I agree with your impression that it seems a strange mission for BSA to request external assistance from CAP.  Expecially since the BSA apparently had professional medical folks (at least the one nurse) on site.  The Volunteer article did not address the background or history of the situation.  But stranger things have happened in CAP . . .

[Krapenhoeffer]

@JThemann: That's kind of what I've been trying to say... I don't know how it is possible to go beyond BLS without an ambulance... Well, except for that really gung ho paramedic I met long ago, and his Truck of Doom... Regardless, I know that I'm never going to have to activate ALS, or be able to for that matter, when playing CAP.

Second thing I'm trying to say. Pretty much any non-life or limb situation can be treated with a bit of basic first aid + common sense. Now, as a matter of habit, whenever I'm dealing with such situations, I don't make physical contact with the patient. I'll just talk the patient through treating his/her self. I don't count that as being "medical care."

If there is a pre-planned CAP activity, where more dangerous things such as repelling or firearm practice are going on, we're going to be on a military installation with its own medical facilities.

In an ES situation, I would be going no further than BLS stabilization, until the ambulance/aeromedical evacuation shows up. If I'm not in my home "trauma region," (the name was pre-white papers) I contact the "Regional Trauma Center" medical director, and get permission to perform BLS in the region. I sign out before doing anything, and I don't introduce myself as a CAP member.

[JayT]

Like I said, you're kinda worrying over nothing.

[RiverAux]

Ned, what are your thoughts on the incident that prompted this thread?

Hard to say.  The only two factoids in the Volunteer article were "roving safety patrols" - which seems fine on it's face assuming adequate senior supervision, etc. - and " first aid teams."

I guess I'm more interested in your take on whether or not providing first aid teams goes against this:

CAP is not an emergency medical care or paramedic organization and should not advertise itself as such. CAP will not be the primary provider of medical support on missions or training events though qualified personnel can be used to support such activities.

[Spaceman3750]

What about the NCSAs that have sick calls run by CAP members... It happens people, and CAPTalk wannabee lawyers aren't going to stop it.

But commanders, staffers, and any officer having genuine concern for the future of CAP can and should stop it.

Do the regs need to change, yes.

Non-concur.

The regs are written the way they are for simple and practical reasons.

CAP cannot be in the business of providing non-emergency medical care for the simple reason that we are not a medical provider.  Medical providers have things like standards, training, protocols for treatment, an adequate infrastructure to provide for oversight and quality assurance in all 52 wings, and most importantly, errors and omissions insurance to cover the inevitable errors that are made by all human beings, including medical officers (and lawyers).

Feel free to price out an insurance plan with any broker that would cover all of our health professionals in all 52 wings (and our overseas units.)  Be sure to tell the broker that you will need to cover not only physicians, PAs, and nurses, but also various kinds of medics ranging from Advance First Aid card holders through paramedics (with a lot of variety in between).  While reasonable minds will vary, I suspect that CAP, Inc will need at least $10-20 million in liability coverage (about a mid-range award for, say, a tragic mistreatment of a cadet rapelling accident that resulted paraplegia).

Tell me what the price you find is, but the last time NHQ checked, we were quoted something like a quarter of million dollars a year.  Which is another way of saying "a substantial dues increase for every single member."

(And, BTW, if I found an extra quarter of a million dollars in CAP's budget, I would probably spend it on other things.  Like cadet scholarships, o-rides, and travel money for basic encampments.  To start.)

Once you have found us some inexpensive insurance, take a moment and think about the infrastructure necessary to provide training and supervision for all of our HSOs in 52 different jurisdictions.  That's a lot of record-keeping and doctrine creation.

Finally, take an additional moment and price out the standardized equipment necessary for all of our medical folks to meet the minimum standards of care in each state.  Things like AEDs, oxygen sets, extraction collars, splints, litters, cardiac monitors, etc.  Don't forget to price out routine maintenance and upkeep, including rotation of supplies.

NHQ is not a cabal of evil people trying to think of ways to deprive you of opportunities to serve your community.  Indeed, it is quite the opposite.  But NHQ and the National Staff do have the responsibility to think policies through carefully, examine the costs and benefits, provide that data to our volunteer leadership that makes the final decisions.

Which they have - the result is a clear, unambiguous regulation that forbids members to render medical care except in genuine emergencies.

And in an emergency, CAP members can and should render all possible care within their resources and training.

Ned Lee
Former CAP Legal Officer
Former EMT

Ned,

A very very well put. I had never put that much thought into it before.

[High Speed Low Drag]

Yes a very thorough explanation.  Thank you, Ned.  These are the things that help keep the membership happy .  I know that technically NHQ doesn't have to give reason for anything they do, but, it definitely improves morale when they do.  Since I am not getting a paycheck from (actually I give my paychecks to) CAP, it does help having things explained.  It is a leadership principal I follow with my subordinates – I always try and explain why I decided to do something one way or another, unless there just is not the time to do so (like when I have a gunman holed up in a house w/ a hostage).

It is too bad that we can't train to do more, but it is understandable.

[CadetProgramGuy]

Then in all honesty and concern, we need to revise the ES Training manuals, and taskbooks.

I realize that every member needs First Aid.  But if we are to abstain from emergent care in the field, then advanced knowledge should be deleted.

Also the task of stretcher carry, should be deleted.  If you don't have knowledge on how to stabilize the c-spine, then you should not carry someone out of the field.

Delete from the regs the EMT Badge.  If you wear one, you are advertising that CAP has the ability to care for prople in the field.

I am half joking and half serious.  The joke is that many people join CAP for the illusion that we search and THEN rescue people.  Rescue by definition means to provide care and transportation from point of rescue to point of care.  The serious part is that because CAP has no medical direction, there is to large of a liability to have emergent rescue crews to work in the field.

If you truly want to save someone, join a rescue service. Otherwise good sam laws are your only protection from lawsuits.  Better know your skills and be very proficient in those skills.

[RiverAux]

Rescue by definition means to provide care and transportation from point of rescue to point of care. 

Rescue is not synonymous with providing advanced medical care.  If we find 2 people sitting by their crashed plane and walk them out of the woods back to civilization, we have "rescued" them.  If we find a a lost 3 year old who has been gone for an hour and is happily picking wildflowers, we have "rescued" them.  Most definitions  revolve around freeing someone from danger. 

But, I tend to agree with the thrust of your other points (hence why I started this thread), that CAP continues to send a lot of mixed messages about both emergency and non-emergency medical issues within the organization. 

[RADIOMAN015]

Rescue by definition means to provide care and transportation from point of rescue to point of care. 

Rescue is not synonymous with providing advanced medical care.  If we find 2 people sitting by their crashed plane and walk them out of the woods back to civilization, we have "rescued" them.  If we find a a lost 3 year old who has been gone for an hour and is happily picking wildflowers, we have "rescued" them.  Most definitions  revolve around freeing someone from danger. 

But, I tend to agree with the thrust of your other points (hence why I started this thread), that CAP continues to send a lot of mixed messages about both emergency and non-emergency medical issues within the organization.

IF you look at the CAP driver liability issues (e.g. make a minor mistake/accident and you pay for it (not gross negligence), you have you answer on this.   Mixed messages means DON'T touch anyone, call in the nearest public safety or others that have current emergency medical response training.  Why take the personal monetary liability chance

In the lost child found by CAP'ers, I'm willing to bet there's is a public safety medical unit at the scene that will evaluate the child, before letting the kid go home.

I don't think too many people walk away from aircraft crashes in the woods.  As another issue with responding ground teams, If there's entrampment in the aircraft, CAP has no cutting tools etc to "rescue" them.  I think we have a great responsibility upon identification of a definite crash site find (by air) to ensure we have a proper interdisciplinary team, which likely will be non CAP members skilled in "rescue/extracation" & the highest possible medical care possible when responding to the scene.   

As far as non emergency care, frankly at encampments CAP should be contracting with an appropriate health care provider (likely either a physicians assistant or primary care nurse practioner, qualified in emergency care) to be on site.  IF there's any medical issues that occur, they will make the determination if a higher level of medical intervention is necessary.

Again there's absolutely no incentive for any senior member to place themselves in a potential liability situation.  Any medical issue (especially with cadets), call 911 and get the individual evaluated by appropriate medical specialist.
RM

[Spaceman3750]

I don't think too many people walk away from aircraft crashes in the woods.

People do wander away from crash sites in the woods, for various reasons. Some are looking for help, and some are just in a daze (think shell shock) and don't know what they're doing. That's why it's my responsibility as a GTL arriving on a fresh scene to try to account for the individuals on board (using passenger manifest or whatever other means we have available), to make sure I don't need to send out hasty teams to find someone.

[Eclipse]

In the lost child found by CAP'ers

Please stop using that term, it's insulting.

As far as non emergency care, frankly at encampments CAP should be contracting with an appropriate health care provider (likely either a physicians assistant or primary care nurse practioner, qualified in emergency care) to be on site.  IF there's any medical issues that occur, they will make the determination if a higher level of medical intervention is necessary.

And who, exactly, is going to pay for that?  CAP doesn't pay anyone else for their services - pilots, technicians, managers, but we should pay for unnecessary medical staff?  Tax dollars are already providing emergency care via 911 - no onsite medical staff is called for, certainly not at member expense.

If your activity is so high risk that you need onsite medical staff, or are away from 911, the ORM numbers are too high (but we've already said that about 1000 times).

[DakRadz]

In the lost child found by CAP'ers

Please stop using that term, it's insulting.

I knew someone else would notice- and I, personally, promise not to use the term anymore.

As far as non emergency care, frankly at encampments CAP should be contracting with an appropriate health care provider (likely either a physicians assistant or primary care nurse practioner, qualified in emergency care) to be on site.  IF there's any medical issues that occur, they will make the determination if a higher level of medical intervention is necessary.

And who, exactly, is going to pay for that?  CAP doesn't pay anyone else for their services - pilots, technicians, managers, but we should pay for unnecessary medical staff?  Tax dollars are already providing emergency care via 911 - no onsite medical staff is called for, certainly not at member expense.

If your activity is so high risk that you need onsite medical staff, or are away from 911, the ORM numbers are too high (but we've already said that about 1000 times).

I do believe we had a Nurse Practitioner at our encampment, though I couldn't confirm. I agree that they should be able to perform their skill set just as the others do, free of charge if they so choose.

[High Speed Low Drag]

Last year at encampment, we had Dr. (Maj) Wilson, who is a general surgeon (who also does family practice) as our Medical Officer.  It was absolutely fantastic.  All med issues were handled, all fakers were put back into drill, and all meds were distributed in an orderly fashion.

[JayT]

In the lost child found by CAP'ers

Please stop using that term, it's insulting.

I knew someone else would notice- and I, personally, promise not to use the term anymore.

As far as non emergency care, frankly at encampments CAP should be contracting with an appropriate health care provider (likely either a physicians assistant or primary care nurse practioner, qualified in emergency care) to be on site.  IF there's any medical issues that occur, they will make the determination if a higher level of medical intervention is necessary.

And who, exactly, is going to pay for that?  CAP doesn't pay anyone else for their services - pilots, technicians, managers, but we should pay for unnecessary medical staff?  Tax dollars are already providing emergency care via 911 - no onsite medical staff is called for, certainly not at member expense.

If your activity is so high risk that you need onsite medical staff, or are away from 911, the ORM numbers are too high (but we've already said that about 1000 times).

I do believe we had a Nurse Practitioner at our encampment, though I couldn't confirm. I agree that they should be able to perform their skill set just as the others do, free of charge if they so choose.

Have you read any of this thread?

1. Without proper equipment, supplies, diagnostic tests, and support, an EMT, an AEMT, a Paramedic, a surgeon, a physician, a nurse practitioner, a physicians assistant, a registered nurse, an LPN, etc etc, is little better able to provide comfort and treatment to someone then your average lay person. This equipment cost money. A lot. And how much do you need to cover the entire US?

2. Who's going to provide medical direction and control? Insurance? Depending on what state your in, an NP or PA may or may not be able to practice on their own. RN's and LPN's are even more limited to what they can do offline. EMT's and AEMT's operate essentially exclusively under the direction of some doctor somewhere.

3. Is every encampment and activity going to have a medical section? What sort of liability are you exposing yourself too if you don't have a medical section are your encampment?