Mixed messages about medical services

[RADIOMAN015]

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?

Yes,  I understand what you are saying -- when I'm talking about emergency medical personnel I mean NON CIVIL AIR PATROL personnel, from either paid or volunteer EMS units. 

It seems to me that for a professional EMT/Paramedic, who also volunteers in CAP this is a "mine field" to stay away from.  IF a liability problem arise. CAP isn't going to help you, based upon the guidance that is given.

Perhaps it would even be better to stay away from ANY ground team involvement, instead spend your time in the air as a scanner/photographer, observer, or maybe something back at mission base.

BTW in my state, EMT's/paramedics are not covered by the Good Samartian law at all  -- which I think is not good either, especially if they are off duty and happend to be driving on the interstate and come upon a serious vehicle accident.  Strange things sometimes happen in our state house and senate.
RM

   

[Major Lord]

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.

You have the right to remain silent. Anything you say can and will be used against you in a court of law. You have the right to an attorney. If you cannot afford an attorney, one will be appointed to you. Do you understand these rights as they have been read to you?

Major Lord

[High Speed Low Drag]

Why?  He took cadets to the ER as he felt necessary, ensured the cadets that were trying to get out of drill were medically fit, and dispensed the meds in accordance with wing policy (before the proposed change came out).  What is the issue?

[Eclipse]

...and dispensed the meds in accordance with wing policy...

Plaintiff's Attorney:  "The Civil Air Patrol dispensed medications?  Isn't that specifically against regulations?"

Defendant:  "No...um...what I meant to say was that we "secured" the meds..."

(See how this game is played?)

[High Speed Low Drag]

Point -

The medical officer provided the cadets, whom had brought medications to the encampment, an oppurtunity at the appropriate times to take their medications as directed by their personal physcians.

Better?

[Ned]

And watch for the new CAPR 160-2 to implement that NB's policy directive that the default position will be that cadets retain their own medications at encampment.

Coming soon to an internet near you.

[Eclipse]

And watch for the new CAPR 160-2 to implement that NB's policy directive that the default position will be that cadets retain their own medications at encampment.

Coming soon to an internet near you.

Isn't it already in force from a policy perspective?  I thought 1 Jan 2010 was the start...

[Major Lord]

Point -

The medical officer provided the cadets, whom had brought medications to the encampment, an oppurtunity at the appropriate times to take their medications as directed by their personal physcians.

Better?

Oh its way too late for that kind of backpeddling.....Its also a non-starter defense. You will have to be sacrificed  to satisfy CAP, Inc. Sorry......Take one for the team and just have your whole staff commit Seppuku now.

Major Lord

[Krapenhoeffer]

@High Speed Low Drag: The Lawyer Overlords demand your firstborn, with which they shall impress him into the Legal Nazgûl, where he shall wander the earth endlessly, drawn by the power of the regs, to secure all power for Mordor Maxwell AFB.

But the regs are clear: Stay away from something that can look like routine treatment. Now, I can't remember the exact AFI, but if I'm not mistaken, Air Force medical personnel can hold sick calls for people of CAP persuasion (I personally think that's more obnoxious than "CAP'pers" I'll keep it), as long as they are billeted on an Air Force facility. Same goes for Army medics on Army posts, etc...

And as for routine prescribed medications, my rule of thumb is that if somebody can't administer their own medication away from home, they need to steer clear of CAP overnights. As for Epipens, I ensure that everyone in my squadron is very familiar with their use and operation, and that if a member carries one, that they make sure that somebody nearby always knows where it is.

For over the counter medications, we have a squadron supplement for 24-hr gear that requires some basic pain killers, anti-diarrhea, and allergy medication. Then I have a list of recommended items. You're going to be eating Lt. Col. Bob's cooking for 4 days, I would advise you to carry the family size Tums with your gear. And I can't give you anything, because that would first involve me calling your parents, and then getting permission from the hospital, and then I have paperwork. So no, I will not give you a Tylenol. You must bring your own.

[Eclipse]

But the regs are clear: Stay away from something that can look like routine treatment. Now, I can't remember the exact AFI, but if I'm not mistaken, Air Force medical personnel can hold sick calls for people of CAP persuasion (I personally think that's more obnoxious than "CAP'pers" I'll keep it), as long as they are billeted on an Air Force facility. Same goes for Army medics on Army posts, etc...

That would be AFI 10-2701, which is the Instruction that outlines the organization of CAP and provides the structure and authorization for
a numbers of areas of military and base support, including emergency medical care.  In cases where the activity or billeting is on an non-USAF facility, the AFI is provided as guidance for the host service with an expectation of care and Space-A support under their similar reciprocal agreements and protocols.

In the case of medical care, it does not specifically authorize Airmen, etc., to provide care as such, but instead references AFH 41-114 (MHSS Matrix), and dictates that CAP personnel on an AFAM are entitled to limited emergency care, and that during other activities CAP Personnel will be provided care via the same system as any civilian.

In nearly all cases on an active military base, that means dialing their equivalent of 911 and being treated by the base's version of EMS.  It does not authorize base personnel to provide routine medical services to CAP members, nor even emergency treatment outside the normal base SOP for EMS.  If Airmen are coincidentally driving the ambulance as part of their duty, you might meet them, but increasingly it is either civilian contractors, or EMS from the local community.

If you hit your head on an AFAM while on base, Uncle Sam pays for the care.  If you hit your head during an encampment, Uncle Sam stabilizes you, but cannot admit you to a military hospital (at least not on a Navy base, BTDT), and you are then either discharged, or transported to a civilian facility as soon as you can be moved.  All on your personal insurance.

[High Speed Low Drag]

And watch for the new CAPR 160-2 to implement that NB's policy directive that the default position will be that cadets retain their own medications at encampment.

Coming soon to an internet near you.

This year we had a FF/First Responder be our primary medic and I (EMT from a looooooong time ago) was back-up medic when he wasn't available.  We were talking about the reg coming soon to an encampment near you.  I was absolutely astounded at the number of cadets that were on antidepressants / mental health drugs.  Floored.  Taken aback. 3/4 of the meds that were "secured" were if these types.  Handing the meds out took at least 45 minutes at morning & evening chow.

Ned - I was originally opposed to the idea of not "securing" the meds.  From an operational standpoint, I am now a believer.  However, I am still concerned about the meds finding their way to other cadets.  This year we found a cadet huffing AXE deodorant - what are they going to do with the meds in the hands of the cadets?  Or do we just say "Nothing I can do" and let the kids (which we wouldn't detect 99% of them doing it) do what they do?

[Ned]

Ned - I was originally opposed to the idea of not "securing" the meds.  From an operational standpoint, I am now a believer.  However, I am still concerned about the meds finding their way to other cadets.  This year we found a cadet huffing AXE deodorant - what are they going to do with the meds in the hands of the cadets?  Or do we just say "Nothing I can do" and let the kids (which we wouldn't detect 99% of them doing it) do what they do?

When the committee was writing (and rewriting and rewriting . . .) the policy proposals we looked really, really hard to find evidence of this problem and we came up blank.  We looked through all the mishap records, all the AARS and encampment reports, and pretty much everywhere we could think to look and did not find a single instance of medication-swapping.  Nor could we find anyone with first-hand knowledge of such an event.

Sure we found lot's of rumors and stories, but no confirmed reports.  Obviously, given the thousands of encampments and hundreds of thousands of attendees since WWII I wouldn't be surprised if it had happend on rare occasions.  But it does not appear to have been a significant problem in the past.

And, of couirse, we are watching for any problems or trends with the new policy. 

But we did find multijple occurances of "cadet urgently needing medication in one place and medications secured somewhere else."  Ultimately it will be a "lesser of two evils" analysis, I suppose.

But I am confident that our experienced and trained CP leaders will be vigilent and concerned for our cadets' health and well being.

Ned Lee

[Redbird Leader]

Ned, I would like your opinion on the following:

I am a Paramedic and plan on being the Medical Officer at an activity inovlving a large number of cadets and senior members. 

I percieve my duties to be the following: 1) Advise the commander of any members participating in the activity that may have medical issues that will affect the activity or CAP, 2) monitor the most common illnesses/injuries, advise the director of those issues and what we may do to prevent them, and 3) transport members to the appropriate medical facilty for evaluation if they complain of illness/injury and, within the limits of HIPPA, advise the commander of their status.

I'm kind of the substitute TAC Officer to transport members to local medical facilities to determine "fitness for duty" so the TAC Officers can remain with the rest of their cadets.

On at least one occasion, I have consulted with the activity director and strongly recommended that a member get a medical evaluation to determine their capability of continuing with the activity and not trying to "push through the pain, man up, etc".

I am strongly against being the caretaker, dispenser, or responsible person for anyone else's medications.  I will, and I will advise TAC Oficers,  to remind cadets and/or seniors to take their medictions as prescribed.  I will also keep a supply of moleskin, Band-Aids (tm), ice packs, and a quiet loaction for breaks.

Sound kosher?

[RiverAux]

Maybe we need a very explicit fact sheet on what CAP members can do at encampments and on missions in regards to medical care.

For example:
"During performance of Emergency Services duties, CAP members who have completed a First Aid Course may do the following to care for persons in medical distress:
1.  Apply direct pressur
2. ...."

"During performance of Emergency Services duties, CAP members with First Responder, EMT, MD or other advanced medical training may do the following and still be covered by CAP's insurance....."

[SJFedor]

Maybe we need a very explicit fact sheet on what CAP members can do at encampments and on missions in regards to medical care.

For example:
"During performance of Emergency Services duties, CAP members who have completed a First Aid Course may do the following to care for persons in medical distress:
1.  Apply direct pressur
2. ...."

"During performance of Emergency Services duties, CAP members with First Responder, EMT, MD or other advanced medical training may do the following and still be covered by CAP's insurance....."

There's no way they'd want to put that in writing. That would be very close to creating a medical protocol, and you start walking a fine line on that. Just saying "to meet the extent of the emergency, within the scope of your training" means it puts it in the member's hands as to what they should or should not be doing, and especially ones with higher medical training should already know what they should or should not be doing.

Not to mention, not all of the first aid provided is on ES activities. Encampments, weekly meetings, other activities all have times when first aid is required.

[Ned]

Ned, I would like your opinion on the following:

I am a Paramedic and plan on being the Medical Officer at an activity inovlving a large number of cadets and senior members. 

I percieve my duties to be the following: 1) Advise the commander of any members participating in the activity that may have medical issues that will affect the activity or CAP,

This is the perfect job for an HSO.  Commanders truly benefit from advice on what to expect from dosclosed medical conditions and how to reasonably accomodate persons with limitations.  Further, HSOs can train the staff on how to care for minor but significant issues like blisters and hydration.  And of course, HSOs can help plan for things like sleep plans and environmental risks like heat injuries and risk assessments for things like obstacle courses, etc.

[2) monitor the most common illnesses/injuries, advise the director of those issues and what we may do to prevent them

"Monitor" is a squishy word, so be careful here.There is no problem with noting trends and pointing out that multiple cases of blisters could bernefit from more frequent sock rotations, Moleskin, and/or a post-shower preventative blister check.  Or counseling a better hydration plan (pee charts, whatever) after a spike in heat injuries.

But if "monitor" means that you are personally assessing cadets, then problems start to present.  That begins to look and feel like diagnosing individual illnesses and injuries, which is problematic.

3) transport members to the appropriate medical facilty for evaluation if they complain of illness/injury and, within the limits of HIPPA, advise the commander of their status.

I guess I have no problems with transporting cadets to "Doc in the Box", but it doesn't really require medical knowledge to drive there and sit around for a couple of hours.  (I use chaplains for this duty whenever possible.  )

And it bears mentioning that since CAP is not a medical provider of any kind, HIPPA does not apply to us in any way.  If it applies to you as a medical provider, that suggests that you are performing some sort of medical provider role, which again tends to cross over into the danger zone.

On at least one occasion, I have consulted with the activity director and strongly recommended that a member get a medical evaluation to determine their capability of continuing with the activity and not trying to "push through the pain, man up, etc".

This worries me.  It sounds like you are using medical knowledge to make medical decisions about what should or shouldn't be done in a given situation.  That could easily wind up being deemed diagnosing and treating in a non-emergency situation.

I am strongly against being the caretaker, dispenser, or responsible person for anyone else's medications.  I will, and I will advise TAC Oficers,  to remind cadets and/or seniors to take their medictions as prescribed.  I will also keep a supply of moleskin, Band-Aids (tm), ice packs, and a quiet loaction for breaks.

Concur.  (And thanks!)

[High Speed Low Drag]

2) monitor the most common illnesses/injuries, advise the director of those issues and what we may do to prevent them

"Monitor" is a squishy word, so be careful here.There is no problem with noting trends and pointing out that multiple cases of blisters could bernefit from more frequent sock rotations, Moleskin, and/or a post-shower preventative blister check.  Or counseling a better hydration plan (pee charts, whatever) after a spike in heat injuries.

But if "monitor" means that you are personally assessing cadets, then problems start to present.  That begins to look and feel like diagnosing individual illnesses and injuries, which is problematic.

3) transport members to the appropriate medical facilty for evaluation if they complain of illness/injury and, within the limits of HIPPA, advise the commander of their status.

I guess I have no problems with transporting cadets to "Doc in the Box", but it doesn't really require medical knowledge to drive there and sit around for a couple of hours.  (I use chaplains for this duty whenever possible.  )

And it bears mentioning that since CAP is not a medical provider of any kind, HIPPA does not apply to us in any way.  If it applies to you as a medical provider, that suggests that you are performing some sort of medical provider role, which again tends to cross over into the danger zone.

On at least one occasion, I have consulted with the activity director and strongly recommended that a member get a medical evaluation to determine their capability of continuing with the activity and not trying to "push through the pain, man up, etc".

This worries me.  It sounds like you are using medical knowledge to make medical decisions about what should or shouldn't be done in a given situation.  That could easily wind up being deemed diagnosing and treating in a non-emergency situation.

I am strongly against being the caretaker, dispenser, or responsible person for anyone else's medications.  I will, and I will advise TAC Oficers,  to remind cadets and/or seniors to take their medictions as prescribed.  I will also keep a supply of moleskin, Band-Aids (tm), ice packs, and a quiet loaction for breaks.

Concur.  (And thanks!)

OK - based on the above conversation, if a cadet comes in and says "I have a headache," what is CAP's position that we should do.  Do we take them to the ER for a headache, or a stomach ache, or what?  Where do we draw the line and how do we draw the line?  We are all aware that the most of the aches and pains come from 1) not wanting to do drill or PT, 2) stress, 3) typical minor, temporary ailments.  When do we go to the ER (and potentially cost the parents $100 or more co-pay) and when do we say, "What do you take at home for these things? - OK here you go."  We have to be mindful that we can't & shouldn't take 20 kids to the ER everyday if they complain of something.  This is especially true of the cadets that have some complaint everyday,

Correct me if I am wrong, but since we are acting in loco parentis [sp], with the appropriate release, do we (CAP staff) not have a right to full disclosure of the diagnosis so we can make the determination as to the continued participation of the cadet?

[SJFedor]

2) monitor the most common illnesses/injuries, advise the director of those issues and what we may do to prevent them

"Monitor" is a squishy word, so be careful here.There is no problem with noting trends and pointing out that multiple cases of blisters could bernefit from more frequent sock rotations, Moleskin, and/or a post-shower preventative blister check.  Or counseling a better hydration plan (pee charts, whatever) after a spike in heat injuries.

But if "monitor" means that you are personally assessing cadets, then problems start to present.  That begins to look and feel like diagnosing individual illnesses and injuries, which is problematic.

3) transport members to the appropriate medical facilty for evaluation if they complain of illness/injury and, within the limits of HIPPA, advise the commander of their status.

I guess I have no problems with transporting cadets to "Doc in the Box", but it doesn't really require medical knowledge to drive there and sit around for a couple of hours.  (I use chaplains for this duty whenever possible.  )

And it bears mentioning that since CAP is not a medical provider of any kind, HIPPA does not apply to us in any way.  If it applies to you as a medical provider, that suggests that you are performing some sort of medical provider role, which again tends to cross over into the danger zone.

On at least one occasion, I have consulted with the activity director and strongly recommended that a member get a medical evaluation to determine their capability of continuing with the activity and not trying to "push through the pain, man up, etc".

This worries me.  It sounds like you are using medical knowledge to make medical decisions about what should or shouldn't be done in a given situation.  That could easily wind up being deemed diagnosing and treating in a non-emergency situation.

I am strongly against being the caretaker, dispenser, or responsible person for anyone else's medications.  I will, and I will advise TAC Oficers,  to remind cadets and/or seniors to take their medictions as prescribed.  I will also keep a supply of moleskin, Band-Aids (tm), ice packs, and a quiet loaction for breaks.

Concur.  (And thanks!)

OK - based on the above conversation, if a cadet comes in and says "I have a headache," what is CAP's position that we should do.  Do we take them to the ER for a headache, or a stomach ache, or what?  Where do we draw the line and how do we draw the line?  We are all aware that the most of the aches and pains come from 1) not wanting to do drill or PT, 2) stress, 3) typical minor, temporary ailments.  When do we go to the ER (and potentially cost the parents $100 or more co-pay) and when do we say, "What do you take at home for these things? - OK here you go."  We have to be mindful that we can't & shouldn't take 20 kids to the ER everyday if they complain of something.  This is especially true of the cadets that have some complaint everyday,

Correct me if I am wrong, but since we are acting in loco parentis [sp], with the appropriate release, do we (CAP staff) not have a right to full disclosure of the diagnosis so we can make the determination as to the continued participation of the cadet?

Well here's the thing. If someone holds a medical licensure or certification, are they acting in loco parentis or are they acting as a medical provider? How do you distinguish the difference, and moreso, how does the law distinguish the difference? For example, parent signs authorization form for as needed ibuprofen, aspirin, pepto, the normal simple stuff. A CAP member who's, lets say, an EMT, administers this in loco parentis, and the cadet has an adverse reaction. When the parents sue, is the court gonna say "as an EMT, it's not within your state protocols to administer this medication, and you didn't have a medical control or physician order to do so" and subsequently fry the CAP member.

I guess what I'm trying to say is, where's the line for medical providers between acting in loco parentis and being medical providers?

[Ned]

Sir,

There will never ever be a bright line in these matters.  Senior members will simply have to use their abundent common sense and worldly experience.

I did not take my kids to the hospital every time they said they had a headache or a tummyache.  This was particularly true if the headache coincidentally developed the morning of the math final. 

(I did take my daughter to the hospital when she complained of severe and persistent abdominal pain that turned out to be ovarian cysts.)

Adults have been taking care of minors and each other for a couple of million years at this point, and most of us have a pretty good sense of what is going to require professional medical care and what does not.  But I will be the first to acknowledge there is no "-10 manual" that will tell you what to do in every possible circumstance.

If after talking with the kid and "looking at the boo boo" (if appropriate), make the call.  If you are unsure, talk about it with the other officers.  Sometimes a quick phone call home can work wonders.  ("Mom, Sally says she has a headache, but I am concerned that she really is afraid she will let the flight down at the drill comp.  Do you have any insight for me?  ( . . .)  Can I have your OK to give her a Tylenol and send her to the drill comp, or would you prefer I take her to the clinic? Can I answer any questions for you?)

When I have been an encampment commander, I have used a variety of methods to help me with this sort of low-level triage.  I have had USAFR medics and nurses on mandays who had protocols from a USAF medical officer to help make the calls.  I have used a non-CAP "camp nurse" (actually the wife of a member) and bought an insurance policy that covered the nurse and CAP, Inc.

But most years, we simply use the common sense and wisdom God gave us.  If we need to send a troop to the urgent care clinic, we do.  Sometimes a couple a day.  (We have eaten hundreds of dollars of costs for uninsured cadets.)

And sometimes cadets get sent home to "recover" with Mom and Dad.

But the bottom line is simply adults making fairly routine adult decisions about the care and welfare of the cadets placed in their charge.  Nothing very mysterious or technical - just common sense.

(Standing by for the "but what if X happens . . . . hypotheticals that would torment and ER physician.)

[High Speed Low Drag]

Ned - Exactly.  I would say that others would argue with you (if you weren't who you are) that you were violating the regs - while others agree with you and say that (like you) it is common sense.  It all stems from what was written earlier and the bright line that the regs suggest.  Here, you sent mixed messages.  Earlier you cautioned against "using medical knowledge to make medical decisions about what should or shouldn't be done in a given situation.  That could easily wind up being deemed diagnosing and treating in a non-emergency situation." - but then you talk about "If after talking with the kid and "looking at the boo boo" (if appropriate), make the call."  And please understand - I'm not trying to ding you - I am confused. (Which is why I am asking questions)

Out of curiosity, how much did that insurance cost you to cover the "camp nurse"?  I think I am going to make the recommendation that next year we have the Medical Group send a nurse over for sick call.  I would also recommend the NHQ draft a medical release statement to reflect the new policy but still provide some latitude for OTC medications to be dispensed to those cadets that did not bring any Tylenol.  (Ex:  we had a lot of female cadets begin "that time of the month" and did not have anything to mitigate the issue.  Being able to provide OTC (w/ express parent consent through release) would have been nice to be able to do).